Jlibiliryofcosgeess. 
1^ j7/.c^tHAz 



I DNITED STATES OF AMERICA^ | 






Entbsbd, according to Act of Congress, in the year 1874, by 

D. APPLETON AND COMPANY, 

In the Office of the Librarian of Congress, at Washington. 



TO 

JAMES R. WOOD, M. D., LL. D., 

BMBBITUS PKOrESSOR OP SITRGERT IN THE BELLBVUE HOSPITAL MEDICAL 
COLLEGE, ETC., ETC., 

AND 

CHARLES PHELPS, M. D., 

nSITINQ SURGEON TO ST. VINCENT'S HOSPITAL, ETC., ETC., 



AS A TOKEN OF EESPECT AND ADMIEATION, 

DUE TO PUEITT OF CHAEAOTEE, SCIENTIFIC ATTAINMENTS, 

AND PEOFESSIONAL ZEAL 

IN THEIE SEAEOH AFTEE TEUTH, 

THIS WORK IS DEDICATED, 

BT THEIE FOEMEE PUPIL 

AND SmOEEE FEIEND, 

THE EDITOR. 



PEE FAO E. 



The following clinical lectures were delivered at the ]^ew 
York' State Hospital for Diseases of the lN"ervoiis System, and 
at the Belle vne Hospital Medical College, by Prof. William 
A. Hammond, and I have collected them with the hope that 
they might serve to add something to the clinical literature of 
nervous diseases. 

I have endeavored to report these lectures in full, and to- 
gether with the histories of the cases, which were prepared by 
myself after careful study and prolonged observation, they 
constitute a clinical volume which, while it does not claim to 
be exhaustive, or to embrace all the diseases of the nervous 
system, will nevertheless be found to contain many of the 
more important affections of the kind that are commonly 
met with in practice. 

As these lectures were intended especially for the benefit 
of students, the chief aim of the author has been to present 
merely practical views, fully illustrated by cases, with the re- 
sults derived from treatment, as far as that was possible ; and 
in so doing he has made no attempt to enter into the patholo- 
gy or the morbid anatomy, but has confined himself to a full 
consideration of the symptoms, the causes, and the treatment 
of each affection, particularly in their relations to the cases. 



V PEEFACE. 

If, in presenting this work to the public, I have succeeded 
in giving an accurate report of the substance of these lectures, 
together with a truthful history of the cases, and their clinical 
results as far as that was practicable, my object will have been 
attained. 

My thanks are due to Dr. Hammond, for many valuable 
suggestions in the preparation of these pages. 

T. M. B. Ceoss, M. D. 
37 West Twenty-fibst St., New York, June 20, 1874. 



OOISTTEI^TS 



LECTURE L 

PAGE 

Partial Cerebral Anasmia, the Result of Thrombosis and Embolism, . 1 

LECTURE IL 

Alternate or Cross Hemiplegia. Case in which there was probable 
Extravasation of Blood into the Pons Varolii, . . 14 

LECTURE IIL 

Congestion of the Spinal Cord. — Chronic Inflammation of the Spinal 

Cord. — Reflex Paralysis, ..... 22 

LECTURE lY. 
Lead-Paralysis. — Chorea, . . . . . . 39 

LECTURE V. 
Aphasia, ........ 54 

LECTURE VL 
Facial Paralysis, . . . ... . . Y8 

LECTURE VII. 
Glosso-Labio-Laryngeal Paralysis, . . . . .88 

LECTURE VIII. 
Cerebral Hasmorrhage.— Paralytic. — Apoplectic, . . 104 

LECTURE IX. 

Cerebral Haemorrhage. — Haematoma of the Dura Mater. — Cerebral 

Thrombosis, with Cross-Paralysis, . . . .117 



Till CONTEIST^S. 

LECTURE X. 

PAGE 

Posterior Spinal Sclerosis, ..... 135 

LECTURE XL 

Posterior Spinal Sclerosis. — Aborted Epilepsy. — Athetosis, . . 141 

LECTURE XIL 

Progressive Muscular Atrophy. — Progressive ^luscular Atrophy and 

Posterior Spinal Sclerosis, ..... 147 

LECTURE Xm. 
Convulsive Tremor, ....... 164 

LECTURE XIY. 
Chronic Basilar Meningitis, . . . . . 171 

LECTURE XV. 

Cerebral Congestion. — Active Cerebral Congestion. — Passive Cerebral 

Congestion, . . . . . . .180 

LECTURE XYL 
Epilepsy, ........ 209 

LECTURE X^^L 
Facial Xeuralgia, ....... 244 

LECTURE XVIII. 
Cervico-Occipital and Intercostal l!^earalgia, . . . 254 

LECTURE XIX. 
Sciatica, ........ 263 

LECTURE XX. 
Organic Infantile Paralysis, ..... 273 

Index, ......... 289 



CLINICAL LECTURES 



DISEASES OF THE NERVOUS SYSTEM. 



LECTUKE I. 



EMBOLISM. 



Gentlemen : The cases wliicli I am enabled to present to 
you to-day illustrate a variety of disease wliicli has lately at- 
tracted considerable attention, not only as regards the imme- 
diate symptoms, but likewise the remarkable secondary con- 
ditions which frequently result. Not many years ago the 
disease in question was confounded with cerebral haemorrhage, 
and other causes of apoplexy, but, thanks to the labors of Yir- 
chow and others, its pathology is now more clearly understood. 
I refer to partial cerebral anaemia produced by obstruction to 
the circulation of the brain by some cause existing within the 
cranium — generally, occlusion of one or more of the cerebral 
arteries. 

This obliteration may be due to two cognate affections, 
namel}^, thrombosis and embolism. I will proceed now to read to 
you the history of the case of William Wice. 

Case I. Ataxic Aphasia with Right Hemijplegia, the Re- 
sult of Thromlosis. — " William Wice, forty-one years of age, 
married, a native of Prussia. Has of late years been engaged in 
the shoe-business. His parents were long-lived, healthy people, 
and he does not remember among his kinfolk any that were 



2 CLIlSriCAL LECTURES. 

afflicted witli diseases of tlie nervous system. He gives no 
liistoiy of ever having had either syphilis or acute articular 
rheumatism, but, on the contrary, says he has enjoyed remark- 
ably fine health until the commencement of his present trouble. 
He is a man of intelligence, and has always led a very tem- 
perate life. During the month of March, 1868, he was seized 
with a dull pain in the right knee, accompanied with numb- 
ness. There soon followed formications and pricking sensations 
limited to the right foot, together with numbness and feelings 
of heat and cold, confined more especially to the toes of the 
right side. From the toes these abnormal sensations gradually 
extended upward, and at the end of two weeks had reached 
the shoulder, when the patient became aware that he was to- 
tally hemiplegic. During this attack his consciousness was 
nnaffected, and his organs of special sense, excepting touch, 
were unimpaired. The 11th of May following, the patient 
suddenly lost the power of speech, but did not even experience 
the slightest disturbance of consciousness. His mind, as he 
avers, was clear, and, although he was nnable to utter a single 
word, yet he imderstood perfectly whatever was said to him. 
He remained completely aphasic for four months, being only 
able during this time to ntter a few sounds, which could not 
be interpreted into intelligible words. 

*' About September, 1868, he began to enunciate a few words, 
at first very slowly and indistinctly, and has gradually acquired 
more facility, although his power of coordination was very far 
from perfect when he first came under our observation. His 
paralysis remained nearly a year complete ; when under treat- 
ment it began to improve. Six months after he was paralyzed 
he had an abscess on the right leg, above the ankle, which re- 
mained open for the period of a year. 

" The patient was admitted to the out-door department of 
the 'New York State Hospital for Diseases of the Nervous Sys- 
tem, August 22, 18Y0, and presented the following points of 
interest : 

" There was hemiplegia of the right side of the body, includ- 
ing the arm and the leg, but the face was unaifected. There 
was no strabismus, no paralysis of the muscles of the eye, nor 
of those of expression. The pupils on both sides were very 



CEEEBRAL THEOMBOSIS. 3 

iiuicli contracted, and jet readily dilated under the influence 
of atropia. The tongue did not deviate to either side. His 
eje-sight, hearing, and other special senses, were imimpaired, 
if we except tactile sensibility. His intellect was as clear 
as ever. There was no loss of the memory of words, no 
impairment of the motor power of the tongue, but simply 
a defect in the faculty of coordination of the muscles used iu 
the act of speaking. The patient found more difficulty in pro- 
nouncing labials and Unguals than gutturals. There was much 
atrophy of the muscles of the right side of the body, but the 
process of degeneration was considerably more advanced in the 
arm. 

'' The arm hung uselessly by the side of the patient, and, with 
the exception of a slight impulse which he could give volun- 
tarily to the fingers of the right hand, muscular power appeared 
to be nearly abolished. He could not bend the arm on the 
forearm, nor raise the arm by means of the deltoid. Motor 
power, as measured by the dynamometer, in the right hand was 
scarcely appreciable. Tactile sensibility, electro-muscular sen- 
sibility, and contractility, together with temperature, were 
markedly diminished in the right arm, while sensibility to 
pain and deep pressure were normal. 

'' The leg was much paralyzed and everted, yet with very 
great difiiculty the patient was able, with the assistance of a 
cace, to move very slowly about. He could not flex the leg 
on the thigh, and when he walked he kejDt the leg perfectly 
straight while he dragged the foot along with a shuffling gait, 
making it at times describe the arc of a circle. The toe was 
caught at nearly every step, owing to paresis of the extensor 
muscles of the leg. Here also there was diminution of tactile 
sensibility, electro-muscular sensibility, and contractility, while 
differences in temperature were easily detected. Bladder, rec- 
tum, and urine, normal. Heart-sounds natural. Lungs healthy. 
He could not whistle, when admitted, from want of power to 
purse up the lips, yet he could expectorate without difficulty. 
In talking he had a peculiar hesitating, stammering manner, 
highly characteristic of his disease, but he did not express that 
impatience and repetition of the same word so often found in 
patients suffering from amnesic aphasia. There were certain 



4 CLINICAL LECTUEES. 

sentences which he was totally unable to pronounce with any 
degree of accuracy, even after much effort, such as ' truly ru- 
ral,' ' National Intelligencer,' ' Peter Piper,' and other words 
abounding in labials and Unguals. After dilating both j)upils 
with atropia the eyes were carefully examined by the ophthal- 
moscope on different occasions, and there was found a circle of 
atrophy around the porus opticus of each eye, together with 
more or less angemia of the vessels of the retina." 

ISTow, let us inquire what is the cause of the hemiplegia 
and difficulty of speech existing in this man. One point, which 
especially engages our attention at the very beginning of his 
history, is the slowness with which the loss of power and sen- 
sibility supervened. We argue from that one fact very defi- 
nitely that the case is evidently not one of cerebral haemor- 
rhage. Peserving any further remarks relative to the diag- 
nosis, let us inquire how nearly his symptoms coincide with 
those met with in thrombosis. 

By thrombosis is understood a condition in which an ar- 
tery, in consequence of a change taking place, imdergoes 
narrowing of its calibre owing to the deposition of fibrine, from 
the blood. The clot thus formed is called a thrombus. One 
of the chief features connected with the development of the 
symptoms in thrombosis is slowness, and you can very readily 
understand why this should be the case. The symptoms which 
are observed are due to ansemia of those parts of the brain 
supplied by the diseased vessel, and as the morbid process by 
which the artery is eventually closed takes place gradually, 
there is therefore no sudden development of the symptoms. 

These very frequently consist, in the first place, of pain 
in the head, vertigo, and more or less confusion of ideas. In 
several cases which have come under my notice the pupil of 
the affected side was dilated, and there were ptosis and stra- 
bismus ; and there may be at a very early period in the prog- 
ress of the disease marked difficulties in the faculty of speech, 
but there do not appear to have been in this instance any 
mental disturbances or others connected with the movements 
of the eye or of the tongue. 

It is one of those cases in which the first evidence of dis- 



CEREBRAL THROMBOSIS. O 

ease is connected witli the loss of power and sensibility in 
some distant part of tlie body. 

Thus in Wice's case there were pain, nnmbness, formica- 
tion, tingling, and other evidences of disordered sensibility in 
the right leg, accompanied with loss of power, and it frequent- 
ly happens that these symptoms exist in very limited regions 
of the body, such as a single limb, or a part of a limb, or they 
may be restricted entirely to some portion of the face. In the 
case of a gentleman now under my care the paralysis is con- 
fined to the muscles supplied by the ulnar nerve, and those 
concerned in deglutition. 

Xow, in the case of Wice we notice further that the paraly- 
sis gradually extended up the limb until the whole side was 
involved, and that with this progress other notable symptoms 
made their appearance. We are therefore justified in conclud- 
ing that the advance in the symptoms was the result of the 
gradual development of the morbid process within the cranium. 

Certainly it is very remarkable that there should have been 
at no time any symptoms indicating derangement of the intel- 
lectual faculties, and none of those such as pain, vertigo, noises 
in the ears, or disturbances of vision, which are so commonly 
associated with brain-disease. One feature, however, is of very 
great interest, and that is the difiiculty of speech, and it is like- 
wise important to notice that the hemiplegia is on the right 
side. Hence we know with certainty that the brain-lesion is 
on the left side. 

There is a very important artery in the brain, called the 
middle cerebral, which is lodged in the fissure of Sylvius. We 
are warranted, by a great many cases in point, in concluding 
that the organ of speech is somewhere in the region of this 
fissure, which, as you know, separates the anterior from the 
middle lobe of the brain. 

Without presuming to define its location and extent with 
as absolute accuracy as some observers, I am satisfied that it is 
in the immediate vicinity of this fissure, and probably, as Broca 
has affirmed, in the posterior part of the third left frontal con- 
volution, or, as later investigations woidd seem to show, in the 
island of Reil. 

It is not my intention on the present occasion to enter into 



b CLIKECAL LECTUEES. 

a full consideration of tlie subject of aphasia, for I shall have 
abundant opportunities during the present session of showing 
you more strongly-marked cases ; I will merely, therefore, say 
now that by aphasia we mean a difficulty of speech either 
resulting from a loss of the memory of words, or due to an 
impossibility of coordinating the muscles concerned in articu- 
lation so as to pronounce them. 

In the present case there is no defect as regards the mem- 
ory of words, the trouble is altogether with the muscles of 
speech. You must recollect, however, that paralysis of the 
tongue or lips may render the speech indistinct or impossible, 
but in this case there is no paralysis of those muscles. The 
patient is able to move his tongue in all possible directions, to 
open and shut his mouth, and to perform all the normal facial 
movements. 

You observe, however, that when I ask him to say a word 
beginning with a labial letter, such as baker or piper, he is 
unable to do so. His mouth closes spasmodically, and no 
sound comes forth. 

The gutturals he can pronounce without difficulty; the Un- 
guals are somewhat troublesome, but not quite so much so as 
the labials. 

He, therefore, labors under what is called the ataxic form 
of aphasia. From the symptoms met with in this case, I think 
we are safe in concluding that the patient is affected with 
thrombosis of the left middle cerebral artery, and that in all 
probability the collateral circulation has been established to a 
considerable extent, for there is no lack of intelligence, and 
there has been no advancement in the symptoms since the 
occurrence of the aphasia, at which time we may presume the 
artery became entirely closed. 

He therefore now suffers simply from the vestigia, or the 
remains, and from which he will continue to suffer unless sub- 
jected to proper treatment. 

Perhaps, before proceeding to the treatment applicable to 
this case, I ought to say something more to you of the natural 
history of the disease in question, but I have no idea of con- 
sidering fully, in the clinical lectures I shall give you here, 
much more than the practical points of the disease under 



CEEEBEAL THKOMBOSIS. 7 

notice, and I have already indicated to you briefly most of the 
importaiit featnres of its course. 

I may, however, say that, as regards causes, thrombosis 
may be due to atheroma of tlie artery, by reason of wliich its 
elasticity is lessened and its lining membrane rendered rough. 
The circulation is therefore retarded, and this condition, with 
the roughened wall, favors the deposition of fibrine upon its 
internal surface. Again, compression may be exercised by 
tumors, whereby the calibre of the artery is diminished, and 
the fibrine thus allowed to accumulate, or the difficulty may 
exist in the heart, which, through fatty degeneration or other 
cause impairing its strength, lessens the force and rapidity of 
the circulation. 

Among the predisposing causes are age, the disease being 
rare in persons under fifty years old, luxurious habits of living 
with insufficient exercise, and, perhaps, inordinate mental ex- 
ertion. 

The prognosis is generally unfavorable, from the fact that, 
although the disease may advance slowly, and may even be 
spontaneously arrested in its progress, the tendency to soften- 
ing always exists. The inadequacy of any medical treatment 
to control the morbid process also renders the prognosis more 
grave. It is rare indeed that the powers of JSTature are so 
effectual in restoring the functions of a brain impaired by 
thrombosis as they have been in the patient before us. 

The treatment proper in this case should be directed to 
the relief of the paralysis, and the restoration of the power of 
speech. Two agents are especially indicated, namely, strych- 
nia and electricity, and perhaps we may derive l^enefit from 
phosphorus. I shall therefore give him a hypodermic injection 
of about one-thirtieth of a grain of the sulphate of strychnia 
every alternate day, apply the induced or Faradaic current 
to the paralyzed arna and leg, and the constant current in such 
a manner as to cause it to act upon the brain, and enlarge its 
blood-vessels, and improve its nutrition. This can be done by 
placing one pole upon each mastoid process, or one upon the 
forehead, and the other upon the nape of the neck, or the 
negative pole over the sympathetic nerve, wliile the positive 
is rubbed up and down the back, from the second or third 



8 CLINICAL LECTURES. 

cervical to the fifth or sixth dorsal vertebra. At the same 
time a mixture, consisting of half an ounce of the phosphorated 
oil, one ounce of the mucilage of acacia, and forty drops of the 
oil of bergamot, should be prepared, of which fifteen drops are 
to be given three times a day in water. Under this plan of 
treatment I shall expect his paralyzed limbs to improve, and 
his speech to become more perfect. 

[N'oTE, — The essential details of tlie treatment above indi- 
cated have been carefully carried out up to the present time 
(Xovember loth), and the case has so far been marked by grad- 
ual progressive improvement. Since October 26th the induced 
or Faradaic current has been applied with advantage to the 
muscles of the tongue and lips regularly three times a week. 
The condition of 'Wice is now as follows : 

There is some hesitation in his speech, but he has much 
more command in coordinating the movements of the muscles 
of the tongue and lips than he had only a short time ago ; 
he can now articulate quite distinctly the words " truly rural," 
•' National Intelligencer," " baker," and " Peter Piper." He 
can pnrse up the lips, although as yet he cannot whistle. The 
pupils are both contracted, but have increased somewhat in size. 
The vessels of the retinge are larger, more tortuous, and fuller, 
and the cii'culation therein has much improved. The degen- 
eration of the porus opticus has not increased. The muscles 
of the right npper extremity have gained so considerably in 
power that the patient is now able to flex the forearm on the 
arm, raise the arm at a right angle to the body, and retain 
things quite readily when placed in his hand. When his arm 
is lifted above his head, he can keep it there voluntarily. The 
improvement in the leg is not less in degree than that in the 
arm and forearm. He can partially flex the leg, although 
very slowly. The foot is still everted, but not to such an ex- 
treme ancrle. When he walks, he lifts the toe well off the 
ground, and swings the leg much less than formerly. All the 
muscles of the diseased side respond to a weak Paradaic cur- 
rent. Sensibility is gradually returning, while the tempera- 
ture and nutrition of the limbs are constantly increasing. 
The patient enjoys excellent health, and has so far i*ecovered 
that he intends to make an attempt to earn his livelihood by 



CEEEBRAL EMBOLISM. 9 

engaging in some light l)iisiness, which only requires a mod- 
erate amount of activity. — T. M. B. C] 

We have another affection by which an artery may be 
closed, and for a complete idea of which we are indebted to 
Yirchow, and that is the condition designated by him embo- 
lism. An embolus is a clot originally formed in some dis- 
tant part of the body, on the cardiac or arterial walls, and 
which, becoming detached by the action of the blood, is car- 
ried by the current to the vessel in which it is subsequently 
found. Here it causes occlusion, producing eifects similar to 
those due to a thrombus. 

[N'ow, you will observe, as regards embolism, that there 
does not necessarily exist any previous disease of the artery, 
which, on the contrary, may be and generally is entirely 
healthy, in which respect there is a marked difference between 
embolism and thrombosis. Emboli may originate in almost 
any part of the body, but they are generally the result of en- 
docarditis involving the left side of the heart, and this in its 
turn is frequently a sequence of acute articular rheumatism. 
You have therefore a very interesting series of morbid phe- 
nomena, beginning with inflammation of the fibrous struct- 
ures about a joint, and ending, in the case of cerebral embo- 
lism, with paralysis, coma, and other symptoms of disordered 
brain-action. 

You will not have failed to notice, gentlemen, from the 
brief outline I have given you of the course of embolism, that 
the symptoms due to occlusion of the artery must be mani- 
fested with great suddenness. A man, for instance, has suf- 
fered from rheumatism, and subsequently from endocarditis ; 
he has mitral or aortic regurgitation, from insufficiency of the 
valves, directly due to fibrinous concretions, preventing their 
perfect action. One of these concretions becomes detached, 
it enters the aorta, and there, following the stronger and more 
direct current, passes into the left common carotid artery, 
thence into the internal carotid, and then, still following the 
stronger and more direct current, enters the middle cerebral 
artery, where it lodges. Such is its ordinary direction. It 
may by chance go into the innominata and subsequently be 



10 CLINICAL LECTUEES. 

arrested in the right middle cerebral artery, or it may pass off 
through the subclavian, and then not enter the head at all. 

But, of the emboli found in the brain, a very large propor- 
tion are discovered in the left middle cerebral artery. 

The relations of the artery to the fissure of Sylvius and the 
anterior lobe of the brain, I have already indicated to you in 
my remarks on the previous case. With these prefatory re- 
marks I will read the following history : 

Case II. Amnesic Aphasia^ with Hight Semiplegia. — 
" Richard Murphy, aged twenty-five years, married, born in 
l^ew York, a weaver by occupation. There is no history of 
any neurosis in his family. He has never had syphilis or 
acute articular rheumatism. He says he has always enjoyed 
good health and been temperate in his habits. One day dur- 
ing I^ovember, 1868, he noticed on taking off his boot that 
his right foot was unusually numb and cold, but he paid little 
attention to thQ fact, as it soon passed away. Being affected 
about this time with a severe vesicular eruption of the face, 
he was persuaded to apply thereto a strong solution of sul- 
phate of iron, which rapidly produced erysipelas of the whole 
of that surface. When the eysipelas had reached its acme, he 
had his first stroke of hemiplegia of the right side just as he 
was descending a flight of stone steps. Suddenly and without 
the least warning, excepting a quick severe vertigo, he fell, but 
immediately arose, and, not yet having recovered himself suffi- 
ciently to have command over his limbs, fell again. With 
assistance he walked a short distance to his house, -when his 
friends discovered that he was paralyzed on the right side. 
His face and tongue were drawn to the left side, while speech 
and memory were slightly impaired. The condition of his 
eye was not noticed. Reasoning aj[>riori^ the patient attributed 
his paralysis to the solution of the sulphate of iron W'hich he 
had used. He immediately began to improve \qyj rapidly, 
and in December following motility having nearly completely 
returned, he was seized with a slight attack of delirium. Dur- 
ing the month of February, 1869, the patient again suddenly 
became hemiplegic, with more marked sequelae than in the 
previous seizure, but he did not wholly lose his consciousness. 



CEEEBEAL EMBOLIS.U. 11 

His leg improved slowly, but mucli more than liis arm. In 
April, 1869, he resumed his occupation, that of a weaver, in the 
factory, but had to do light work on account of the deficient 
muscular power in his right arm. In July he had a third 
seizure, but after falling he immediately went to work again. 
From this time until May, 18T0, he busied himself about the 
factory, and attended regularly to his daily avocations. His 
appetite and nutrition did not seem to be impaired, and he 
appeared to enjoy very good health. In May, 1870, suddenly 
the patient again became paralyzed ; this time the paralysis 
involved the right leg more than the arm, but, owing to the al- 
ready existing paralysis of the riglit upper extremity, it is very 
likely that attention was not called thereto. There was no loss of 
consciousness. The muscles of the eye, face, and tongue, were 
not afiected. With assistance he walked home, and in about 
a week had quite recovered from this attack. The treat- 
ment had been, up to this time, strychnine internally, with 
blisters behind the ears. During July last, while chopping 
wood, he was suddenly taken with an intense pain in the left 
side of his head, followed by vertigo; after falling, he arose, 
but again fell. On examination, his left pupil was found 
widely dilated. The patient was incoherent and delirious for 
four days. There was no apparent increased paralysis during 
this attack. After three weeks had elapsed, the patient went 
to work, but it was evident that his eye-sight and memory 
were much impaired. All these attacks were ushered in by 
a sudden severe vertigo, but were never followed by any con- 
vulsive movements. 

"" The patient was admitted to the Out-door Department 
of the New York State Hospital for Diseases of tlie JSTervous 
System, September 1, 18Y0, when he was found to be in 
the following condition : There was deficient muscular power 
on the right side, although very slight in degree. The right 
arm was more paralyzed than the leg. The patient, how- 
ever, said he was as strong as ever in that part of the body. 
His face had a peculiar, meaningless expression, differing from 
the intelligent look of many aphasic patients. The right side 
of the face was not at that time paralyzed. There was the 
loss of the memory of words, but no paralysis of the muscles 



12 CLrNTCAL LECTURES. 

of the eve or of the tongue, and no defect in the coordination 
of the muscles of the tongue used in the act of speaking. 
Eve-sight impaired. Patient coukl not read or write. He 
understood whatever was said to him perfectly, yet, if he were 
asked to repeat a complex sentence, the memory of the words 
had departed, and he could not recall them. Bladder and 
rectum were normal. Sensihility on the right side was normal. 
The patient is naturally left-handed, which may account for 
the difference in muscular power. A sister has heart-disease, 
and the patient liiniself has h\^ertrophy with aortic insuffi- 
ciency. Lungs were healthy. His lips and face are livid, and 
at times when he is cold this condition becomes quite striking." 

Xow let me proceed to give you an outline description of 
an ordinary attack of cerebral embolism. In the first place, 
there are no premonitory symptoms: the individual is perhaps 
engaged in his ordinary avocations, or is perfectly quiet, when 
he suddenly becomes apoplectic, and falls to the ground. His 
breathing is stertorous, his pulse slow and full, and the insensi- 
bility more or less complete. As soon as he can be aroused to 
such an extent as to enable him to execute volitional move- 
ments, it is found that he is partially or entii'ely paralyzed on 
one side of his body. Such is the severe form of the attack, 
and from this there are almost innumerable gradations to seiz- 
ures of less gravity. Thus it often happens that consciousness 
is not lost ; the patient falls simply from paralysis ; and this 
loss of power may extend throughout the whole of one side, 
be limited to one or the other limb, or to the muscles of the 
face, or be restricted entirely to the tongue. 

The subsequent history is very similar to that of a case of 
hemiplegia from cerebral hemorrhage, but differs in the very 
important points that the paralysis and other symptoms are 
more or less transitory, and, as far as my experience extends, 
there are no muscular contractions. I have seen several cases 
in which the faculty of speech was alone involved, either as re- 
garded the memory of words or the power to articulate them by 
coordination of the proper muscles. 

The duration of the symptoms depends upon the rapidity 
with which the collateral circulation is established, and, if the 



CEEEBRAL EMBOLISM. 13 

embolus be small and the physical powers of the patient good, 
they may last but for a very short time. 

Trousseau, in his lecture upon aphasia, relates the case of 
one of his colleagues, who, while reading quietly in his library, 
suddenly discovered that he could not utter a single word. 
There was no paralysis any w^here, no loss of consciousness, and 
but slight confusion of ideas ; at the end of twelve hours recov- 
ery was complete. There can be no reasonable doubt but that 
this was a case of cerebral embolism. 

In the case of Murphy, there were ^ve distinct attacks, all 
involving the right side, and accompanied with some difficulty 
of speech. From all there was tolerably complete recovery, 
so that even now there is scarcely a trace of paralysis in any 
part of his body ; neither do there appear to be any mental 
symptoms except as regards the memory for words ; in other 
respects, his memory is hardly at all impaired, his recollection of 
locality and circumstance is good, and his intelligence fully up 
to the average of his class. But if I ask him to repeat even a 
short sentence, such as "' Will you go with me to the theatre ? " 
or to say three or four consecutive words, as " tea, sugar, and 
coffee," you observe he is unable to do so. He utters the first 
word, stops, looks confused, and is unable to proceed ; and yet 
there is no difficulty whatever in his enunciation : what he 
does say he says with perfect distinctness. 

]^ow, from what I have said to you of embolism, and from 
a consideration of the history of this case, can there be a rea- 
sonable doubt that each attack of hemiplegia was due to an 
embolus — probably a small one lodging in the left middle cere- 
bral artery — and that our assurance is rendered doubly sure by 
the fact that we find that condition existing in his heart wdiich 
is best calculated to cause the formation of emboli on its lining 
membrane ? 

At times we have very great difficulty in distinguishing 
emboli from cerebral haemorrhage. The phenomena of both 
conditions are often very similar, but the transient character 
of those due to embolism, the fact that the resultant hemi- 
plegia is almost always on the right side, and that there is a 
history of rheumatism or organic disease of the heart in the 
case, will ordinarily enable us to make a correct diagnosis. In 



14 CLINICAL LECTUEES. 

the present case the treatment need not be very complex. I 
am inclined to think that phosphorus will prove beneficial, and 
that advantage may be gained by the passage of the primary 
current directly through the brain. At the same time much 
can be done for him by exercising his memory in regard to 
language. Several cases are on record, and one has occurred 
in my own experience, in which individuals much more apha- 
sic than Murphy have again acquired the power of language 
by persistent and well-directed attempts to recollect words 
spoken to them. 

On a subsequent occasion I shall bring this patient with 
others before you, and speak at greater length on the subject 
of aphasia. 

LECTUEE II. 

ALTERNATE OK CROSS HEMIPLEGIA. CASE IX WHICH THERE 
WAS PROBABLE EXTRAVASATION OF BLOOD INTO THE PONS 
VAROLII. 

'No disease that I shall have to lecture upon to you is more 
important than cerebral haemorrhage ; we meet with it at all 
times, in all persons, and under all circumstances. It is a dis- 
ease to which a certain class of individuals have reason to look 
forward with apprehension, for in an instant their lives may be 
destroyed, or they may be rendered imbecile or may be crippled 
for life. 

It is only recently that medical writers have to any extent 
adopted the custom of naming a disease in accordance with its 
morbid anatomy ; they have been too much in the habit of 
basing their nomenclature upon some one prominent symptom, 
which may be, and in fact generally is, common to several 
very different pathological states ; thus, it was the case, and 
still is to a very great extent, that cerebral hgemorrhage was 
considered under the name of apoplexy ; it would be just as 
proj)er to treat of phthisis under the designation of cough, for 
apoplexy is simply a symptom which we meet with in several 
very different cerebral affections, just as cough is not peculiar 
to any one disease of the lungs. 

Cerebral h£emorrhage is a term applied to an extravasation 



CEOSS-PAEALYSIS. 



15 



of blood occurring eitlier in the tissue of the brain or in its 
ventricles. It does not include meningeal hemorrhage, which 
takes place upon the surface of the brain, and differs from it 
in several other important particulars. The effusion of blood 
is due to the rupture of a cerebral blood-vessel, and this rup- 
ture is ordinarily the result of a diseased condition of the vas- 
cular parietes. 

This much is perhaps necessary as an introduction to the 
very interesting history which I will now proceed to read to 
vou : 



Cerebral Hcemorrhage with Cross- Paralysis and Left 
Hemiplegia. — " John J. H. Fetter, forty-two years of age, mar- 
ried, born in Pennsylvania. Has always followed agricultural 
pursuits until within a few years, when he learned the book- 
binding business, at which he has since worked. Tie is the 
father of fourteen children, of whom at the present time five 
are living. Eighteen years ago he had rlieumatism, which suc- 
ceeded a severe attack of gonorrhoea, since then he has had 
gonorrhoea several times and a soft chancre, but gives no his- 
tory of syphilis. 

" His mother's grandmother had paralysis at an advanced 
age, and with that exception his family, so far as he is aware, 
is perfectly free from any of the marked forms of disease of the 
nervous system ; but it is a curious coincidence that, while he 
is paralyzed on the left side, his wife is hemiplegic on the 
right. He has been a temperate man in all respects, if we ex- 
cept, perhaps, venereal excess, for the sexual passions in this 
patient are very highly developed. He says he has labored very 
hard all his life, and confined himself very closely to business. 

" If we exclude rheumatism, gonorrhoea, and bilious remit- 
tent fever, the patient enjoyed for thirty-three years tlie very 
best of health, which was not otherwise marred, until the on- 
set of this attack of paralysis which occurred on the evening 
of the 11th of October, 1861, while Mr. Fetter, who w^as at 
this time convalescing from a bilious remittent fever, was sit- 
ting quietly by the fire, when his attention was called to his 
left leg and foot, which had become quite devoid of feeling ; 
thinking that it was onlv the sensation of numbness which we 



16 CLINICAL LECTUEES. 

SO often experience when pressure is made on the sciatic nerve 
while sitting, he arose and began to walk about, but discov- 
ered that it required more activity and a greater length of 
time for the leg to regain its accustomed sensibility than is 
usual when a person's foot is simply asleep as it is termed. 

" After a while, however, this abnormal numb sensation dis- 
appeared, and the patient, feeling as well as ever, soon retired to 
rest, but was hardly asleep when he was aroused by the nurse 
for the purpose of fitting a key to a bureau drawer ; he arose, 
executed her request, and returned to bed apparently without 
any difficulty, but shortly after this, desiring a glass of water, 
he called to the nurse, w^ho, on arriving, was alarmed at the 
aspect of her patient, whose face was awry, and w^hose mouth 
was drawn to the left side. She now handed him a glass of 
water ; he put the glass to what he supposed was his mouth, 
and as he imagined drank the contents, but soon discovered 
that he had poured the water all over himself and the bed. On 
moving about while in the dark. Fetter caught hold of his own 
left hand, but was not conscious of that fact, and would not be 
convinced until a light was brought and the truth proven, 
when the reality that he was paralyzed first flashed across his 
mind. 

" On being examined after this attack, there was found to be 
loss of motility and sensibility on the left side of the body ; 
the face was drawn to the left side, and this fact is still 
further corroborated by Mrs. Fetter, besides the testimony of 
the nurse and Mr. Fetter ; the sensibility on the right side of 
the face was unimpaired. Yision in the left eye was so much 
affected that he could not read at all. There was no loss of 
consciousness, no premonitory symptoms whatever, excepting 
the sensation of numbness in the left leg and foot. His intel- 
lect was perfect, his memory was unafiected, and his special 
senses, excepting as regards the impairment of vision in his 
left eye and the anaesthesia on the diseased side, were natural. 
The bladder and rectum were at first normal, but after a while 
slight incontinence of urine followed. 

"He remained in bed, unable to move, for about seven 
months before any change in his condition for the better took 
place, and then he began to improve, very gradually indeed. 



CROSS-PARALYSIS. 17 

and in time could go about by msans of a cratch, whicb lie con- 
tinued to use for nearly a year, the leg during this psriod 
making the most progress. Then he laid aside the crutch and 
manao-ed to walk with a cane, and in the due course of events 
he was able to move about without any artificial suppoH, and 
has for the last seven years used nothing wdiatever to assist him 
in walking. During the early stage of the disease there was 
some amendment in the arm, but latterly there seems to have 
been none whatever. He has passed through the hands of 
many physicians, but without receiving much apparent benefit. 
While he was confined to his bed he had frequent nocturnal 
emissions, and, after he was able to be up and about, his virile 
power was abnormally exalted. 

" About the middle of May, 1862, he commenced to have 
well-marked epileptic fits, which were attended with complete 
loss of consciousness and preceded by vertigo. These fits re- 
curred at regular intervals twice a week for a period of nearly 
four years, when they began to decrease in frequency, although 
they did not change their type, as is often the case, and have 
continued to diminish until June, 1870, when he had an un- 
usually severe attack, which was the last. 

" The patient was admitted to the Out-door Department of 
the ]S"ew York State Hospital for Diseases of the Nervous Sys- 
tem, September 19, 1870, when the following points pertain- 
ing to his condition were at that time ascertained : 

" His heart and lungs are perfectly healthy, general health 
is excellent, appetite is good ; bowels are regular ; urine is nor- 
mal and there is no incontinence ; vision on the left side is as 
good now as ever ; the left pupil is slightly dilated or the right 
slightly contracted. The tactile sensibility of the whole left 
side of the body is diminished to a great degree ; the motility 
is impaired, but this depends more on the lack of nervous en- 
ergy than on atrophy or want of contractility in the muscular 
fibre. There is no facial paralysis, no difficulty in moving tlie 
tongue, no impairment of speech. His intellect and memory 
are as perfect as ever. There is no change of character, nor 
undue display of emotional feeling, which is so often evinced 
in those sufi"ering from cerebral hgemorrhage. The tactile sen- 
sibility on the right side of the face is normal. Special senses. 



^ 



18 CLINICAL LECTURES. 

excepting the anesthesia of the left side, unimpaired at present. 
Sexual appetite is increased. On examining the eyes by the 
ophthalmoscope, they are both found to be in a perfectly 
healthy condition. 

" Upper Extremity of the Left Side. — The arm hangs pow- 
erlessly by his side, with the forearm fully extended, and the 
lingers are drawn more or less into the palm of the hand. He 
cannot flex the forearm nor extend the fingers in the slightest 
degree, but can manage to raise the whole extremity a little 
by means of the deltoid muscle. The shoulder is depressed 
and inclined inward. There is some rigidity about the mus- 
cles of the fingers and hands, owing to secondary changes which 
have taken place. There is no observable atrophy of the mus- 
cles of the arm and forearm, and, as far as muscular develop- 
ment is concerned, they seem to be well nourished. The tac- 
tile sensibility is considerably diminished, while motility is 
greatly impaired, and to a much greater extent here than in 
the leg. The dynamometer indicates no expenditure of power, 
and this is evidently more on account of the inability of the 
patient to grasp the instrument, owing to the rigidity of the 
fingers, than from total want of muscular force. The sensa- 
tions of heat and cold are diminished ; tickling the palm of the 
hand is not felt, nor are reflex movements excited thereby. The 
sensation of pain is increased, as evidenced by the application 
of the electric current, while the sam.e means shows that mus- 
cular contractility is diminished. The temperature is dimin- 
ished, but sensations of deep pressure are increased. 

^^ Lower Extremity of the Left Side. — The patient has con- 
siderable strength in this limb, and is able to walk about, yet 
he limps and has little control in directing its movements. 
The foot is strongly adducted, and the toe catches whenever 
he goes about, and when sitting down he is totally unable to 
raise the diseased limb volimtarily so as to cross his legs. Tac- 
tile sensibility, together with the sensations of heat and cold, 
is diminished, and so is temperature. Muscular contractility, 
as shown by the galvanic current, is diminished. Tickling the 
sole of the foot is not felt, nor are reHex movements excited 
thereby. Sensibility to deep pressure, pain, and electricity, is 
increased. There is a difference by measurement in the legs, 



CEOSS-PAE ALYSIS. 1 9 

wliicli shows that the left is an inch and a half the smaller in 
circumference." 

The point of greatest interest in relation to this case is the 
alternate hemiplegia or cross-paraljsis, in regard to the pre- 
vious existence of which there appears to be no doubt. The 
arm and leg of the left side were paralyzed, the face was 
drawn to the same side, which of course shows paralysis of the 
right facial nerve. You know this is an exception to the gen- 
eral rule, which is, that the face and the rest of the body are 
paralyzed on the same side, and I therefore ask your especial 
attention to the circumstance. I have seen but two similar 
cases in the whole course of my experience. 

And, first, let me recall to your recollection certain points 
in the anatomy of the seventh pair, or facial nerve, which is 
the principal motor nerve of the muscles of the face, and the 
one affected in cases like the present. 

The apparent origin of this nerve is from the side of the 
pons varolii, although its fibres can be traced much higher up, 
even as far as the floor of the fourth ventricle. They decus- 
sate somewhere above the pons, the exact point not having 
been ascertained, and the fact being denied in toto by some 
anatomists. A point, however, which I shall mention to you 
presently, shows that the decussation does really take place, 
and that the crossing over must be above the pons. 

After leaving the side of the pons the facial passes through 
the aqueductus fallopii to the stylo-mastoid foramen, and is 
distributed to all the muscles of the face, excepting the ptery- 
goid and the masseter. An extravasation of blood occurring 
in the pons on one side of the mesian line must paralyze the 
facial of the same side ; so much for that division of the phe- 
nomena in this case. 

The fibres of the anterior roots of the spinal nerves which 
are motor continue in the anterior columns, until they reacli 
the lower part of the medulla oblongata, when they decussate, 
those of the right side passing to the left, and mce versa. 

The fibres connected with the posterior roots likewise cross 
over to the opposite side of the cord, but they do so immedi- 
atelv after their entrance. Both sets therefore decussate be- 



20 CLINICAL LECTUEES. 

low the pons, and consequently a lesion of one side of this 
ganglion paralyzes both motion and sensation, on the opposite 
side of all that part of the body supplied by nerves arising 
below the point of decussation. But the crossing over of the 
facial nerves, as I have just told you, takes place above the 
pons, and consequently such a lesion must produce paralysis 
on the corresponding side of the face. 

ISTow, the decussation, although difficult to see as an ana- 
tomical fact, is very conclusively proved by pathology, for an 
extravasation occurring in the corpus striatum of one side, for 
instance, paralyzes the opposite side of the body, face included, 
a fact which shows that the decussation of the facial has taken 
place below the seat of the lesion. 

Another symptom present in this case indicates a lesion of 
the pons, and that is the epileptic paroxysms from which he 
has suffered. Although this phenomenon, if taken by itself, 
is not very definite, it is of importance when viewed in con- 
nection with the cross-paralysis. 

And then a circumstance indicating the pons as the situation 
of the extravasation is the total loss of the faculty of reflex ex- 
citability, which you will recollect was especially mentioned in 
the history. JSTumerous experiments and observations serve to 
show that the pons is a grand centre of reflex action. Lalle- 
mand ' mentions a case in which a child was born without 
cerebrum or cerebellum, and with no ganglion within the cra- 
nium excepting the pons varolii, and the medulla oblongata, 
and yet this child was able to suck, to make movements with 
its arms and legs, and apparently was possessed of as much 
muscular power as other children of its age. Many other 
similar cases are on record, and they certainly do show that re- 
flex movements are not dependent on the higher ganglia of the 
brain for their manifestations. 

This doctrine of cross-paralysis, pointing conclusively to 
lesion of the pons, is not universally admitted. Trousseau 
questions it on the basis of one case, in which the hemisphere 
was the seat of the extravasation, and I have myself seen one 
in which the hemisphere was apparently the only part of the 

^ Eeclierclies anatomico-patliologiques sur I'encgpliale et ses dgpen- 
dances. Paris, 1824. 



CROSS-PAEALYSIS. 21 

brain involved. Still a case or two should not be allowed to 
stand against the large number referred to by Gubler and 
Lnys. 

As regards the treatment of this case there is not mnc^h to 
say. The epileptic paroxysms seem to be gradually disappear- 
ing, the paralyzed muscles of the face have regained their con- 
tractility, and nothing remains to be done but to restore, as 
far as we can, power to the arm and leg. This we shall try 
to do by hypodermic injections of strychnia, in doses of a 
thirtieth of a grain every alternate day, and by the use of the 
primary galvanic current, until the contractility of the mus- 
cles is so fiir restored as to render the use of the induced cur- 
rent advisable. 

[XoTE. — The treatment indicated above has been followed 
out in this case up to date, !N^ovember 19, 1870, the patient 
every alternate day receiving a hypodermic injection of the 
thirty-second of a grain of strychnia, together with the ap- 
phcation of the primary galvanic current to the paralyzed 
limbs three times a week. October 1st, the induced or Fara- 
daic current having first produced contractions in the muscles 
of the forearm, hand, and fingers of the diseased side, this was 
employed from that date, in addition to the above means, as 
the conditions of the case demanded, sometimes one current 
being used, at others both. October Zlst. — The tactile sen- 
sibility in both the arm and leg is beginning to return. In 
short, the improvement has been gradual and steady, and at 
the present time the condition of the patient is as follows : 
He can flex the forearm on the arm, touch his forehead w^ith 
his left hand, flex and extend the fingers slightly. The toe 
does not drag, nor does he swing his leg very much. He can 
cross his legs without any diflSculty. The foot is not adducted 
so much, and he can move it directly forw^ard or backward', 
which he could not do two months ago. The muscles of both 
the leg and arm respond well to the Faradaic current, although 
muscular contractility is still diminished. The sensation of 
tickling is felt, but not so well as in the right leg, and the re- 
flex excitability is abnormally impaired. Sensations of deep 
pressure, heat, and cold, are normal. Tactile sensibility has 
returned to a considerable degree. Sensibility to the electric 



22 CLIiaCAL LECTUEES. 

current is much increased. Temperature lias increased. He 
has had no epileptic attack for live months, and his general 
health was never better than at preseut. — T. M. B. C] 



LECTUKE III.^ 

CONGESTION OF THE SPINAL COSD. CHRONIC INFLAMMATION OF 

THE SPINAL CORD. REFLEX PARALYSIS. 

At the previous clinical lectures, I brought before jou 
several examples of ^^aralysis — cases due to cerebral haem- 
orrhage, to embolism, and to thrombus. The cases which I 
shall present to-day are examples of spinal paralysis ; and I 
wish you to pay particular attention to the diagnostic marks 
which distinguish them from those you have before seen. I 
will first read the histories of the three patients before you : 

Case I. — " Eose Peyton, twenty-seven years of age, born in 
Ireland ; mother of two children, both of whom are living ; 
the elder has talipes valgus, while the younger is a tine, hearty 
child. Her family is very healthy, and there is no evidence 
of nervous diseases either in it or in any of its branches, so far 
as she is aware. The patient was a strong, active woman, and 
always did her own work until twelve weeks ago. In May 
there was a cessation of menstruation, and in July last she was 
seized with a deep, dull, aching pain in both legs, which ap- 
peared to her to be in the bones. There is no syphilitic taint 
in her history. There succeeded shortly after a severe pain in 
the back, which has continued up to the present time, but 
which has varied in intensity. Soon loss of motility, numb- 
ness, and anaesthesia, made their appearance in both legs, and 
in the course of two months she was totally unable to walk at 
all. At first her bowels were very costive, but soon this con- 
dition was superseded by incontinence of the rectum, which 
lasted for two weeks, varying in degree. There was also re- 
tention of urine. Sensations of formications, alternating with 
numbness, of heat and cold, of pricking by pins and needles, 

^Reported plionographicallj by Dr. John Winslow. 



SPIIS-AL PAKALYSIS. 23 

were present not only in the feet and toes, but also in the hands 
and iiiigers. Patient noticed that, on rising in tlie morning, 
after a night's rest, lier limbs were weaker, and that she 
had greater difficulty in moving about. The paralysis, after 
commencing in the lower extremities, rapidly extended to the 
upper. August 2hth. — Was able to get out of bed for the iirst 
time in five weeks, and by means of a chair could move about 
a very little. Since then she had improved only so mnch as to 
be able to come to the Out-door Department of the IS^ew York 
State Hospital for Diseases of the l^ervous System, by being 
supported by a person on either side, and only then with ex- 
treme difficulty. She was admitted September 22, 1870, wdien 
she was found in the following condition : Motility and tactile 
sensibility in both legs greatly impaired, but the right leg is 
the weaker of the two. Left hand, as measured by the dyna- 
mometer, is much feebler in power than the right, and this to 
a more marked degree than any normal disparity. Sensa- 
tions of formication, alternating with numbness, of heat and 
cold, pricking by pins and needles, and tingling, still continue 
in the feet and toes, as also in the hands and fingers. Pain in 
the back increased by pressure and percussion, but no burning 
sensation of applying heat and cold. The anaesthesia is more 
marked in the thighs than in the legs. Soreness in the soles 
of the feet. Eowels constipated. Bladder normal. Electro- 
muscular contractility and sensibility greatly diminished. ISTo 
band around the waist. I^o spasms, twitchings, nor reflex 
movements in the legs. Pain in the lower extremities as at 
first. Changes in the degree of the paralysis from time to 
time. Temperature diminished. The circumference of the 
legs is diminished to a marked extent, owing to the atrophy of 
the muscles. Heart and lungs healthy. Urine not examined." 

Case II. — " Joseph White, thirty-two years of age, born in 
Ireland, blacksmith by occupation ; father of four children, all 
of whom are at the present time alive and well. He has never 
had syphilis, nor in fact any disease since his childhood. At 
times he has drunk to excess, but not habitually. His family 
line is free from the neuroses. The patient was a strong, hale 
man, having enjoyed the best of health, and always working 



24 CLINICAL LECTUEES. 

very liard and diligently at his business, until the 12tli day of 
August, 1868, when he slipped and fell, striking the right side 
of his forehead at the outer canthus of the right eye against 
the edge of a tub, inflicting a severe lacerated wound. This 
remained open two months, and before healing was attacked 
with erysipelas, which was yery severe and lasted a month. 
As soon as the erysipelas disappeared the wound of the face 
began to granulate and was quickly cicatrized. During this 
attack the patient was a greater part of the time confined to 
his bed. October 12, 1868, went to w^ork as usual, and noticed 
that his hands trembled very much, and was every now and 
then seized with a severe attack of vertigo. His vision was 
more or less impaired, but in the course of a month was the 
same as ever. There was no loss of consciousness nor any in- 
voluntary muscular contractions during these seizures. He 
continued in this condition until July 1, 1869, when he was 
suddenly taken with a dull, aching pain in the lumbar region 
of the spine, which lasted for four weeks, and disappeared un- 
der the continued application of blisters. At this time there 
were no spasms in the muscles of the back. His attention was 
next called to numbness in the great toe of the right foot, which 
gradually extended to the ankle, and in the course of two 
weeks the whole les: became involved. He now became aware 
that motility was diminished in the right lower extremity. 
His bowels became very constipated, and a second attack of 
pain in the back supervened, which was not so acute as the 
former seizure. This pain remained steadily for a period of 
five months. January 1, 1870. — Was troubled for tlie first 
time with retention of urine. His left leg now began to grow 
weak, and this loss of power gradually increased. There was 
no abnormal sensation of numbness in it, as in the riglit. He 
remained in this state of incomplete paresis for a short time 
only, as the disease made such rapid progress that in March 
he was just able to get about, by means of a cane, with the 
greatest difficulty and exertion. The right leg was more par- 
alyzed than the left, and tactile sensibility was diminished only 
in the former. Severe spasms and twitchings in the muscles 
of both legs now set in, and his attention was soon called to 
sensations of heat and cold, formications, swellings of the calves 



II !! 



SPIN'AL PAEALYSIS. 25 

of the legs, and prominence of the superficial veins of both 
lower limbs. For three months he remained in about the same 
state. Jy>ne \st. — He began to improve in walking, but was 
troubled very much with severe pains in both legs, which were 
at one time darting, at another dull aching, and seemed to 
start from the joints. September 1st. — Had a feeling of con- 
striction or band around the waist, which has continued to the 
present time. He has improved in walking very gradually 
since June 1, 1870. He applied for admission to the Out-door 
Department of the JN'ew York State Hospital for Diseases of the 
^STervous System, October 3, 1870, when the patient was found 
in tlie following condition : Motility impaired in both legs, but 
not to any very great extent. The left leg is weaker in mus- 
cular power than the right. Sensations of heat and cold, for- 
mications, prickings by pins and needles, in both limbs. Ke- 
flex power greatly exalted. Twitchings in both legs. Cord 
around the waist. IS^umbness in right leg. Retention of urine. 
Bowels constipated. Severe darting pains in the legs. Slight 
pain in the back not increased by pressure and percussion. 
'No burning sensation along the spine by application of heat or 
cold. Tactile sensibility in both legs normal. Urine markedly 
acid. Cannot stand up with his eyes closed, for he immedi- 
ately loses his balance. Cannot walk in the dark at all. His 
gait is peculiar, and is better appreciated by being seen than 
described. The remaining points of his condition at the pres- 
ent time are negative in character. 

Case III. — ''Elbert Baxter, forty years of age, single, born 
in the State of New York ; showman by occupation. 

" The patient had been a very healthy man until the year 
1859, when his present disease commenced. He has always 
been remarkably temperate in his habits ; having been ad- 
dicted to no excesses of any kind. He has never had syphilis, 
nor suffered from any spinal injury. His father w^as attacked 
with hemiplegia of the left side when sixty-three years old, and 
his aunt on his mother's side was paralyzed when fifty years of 
age. All his other relations w^ere free, as far as he is aware, 
from the neuroses. In the year 1859, having passed a night 
where he was obliged to sleep in a very damp place, he was 



26 CLINICAL LECTURES. 

soon after tliis exposure seized witli a dull aching pain in 
the small of his back, accompanied with nausea and vomiting. 
A short time having elapsed, there followed, first, loss of vigor; 
andj secondly, incontinence of urine, which was soon succeeded 
by a slight weakness of the lower extremities. This paresis of 
the legs gradually increased during a period of about six 
months, when it became almost complete paralysis. In July, 
1860, he noticed that he was unable to exert volitional control 
over his rectum, and, if he did not immediately attend to the 
calls of Xature, his faeces passed involuntarily. This condition 
lasted several months, and varied in degree according to cir- 
cumstances. At this time he entered the Kilkenny Hospital, 
in Ireland, where he was treated for three months for what 
was there called the creeping palsy, but, getting no better, he 
went to London, and after remaining there several months 
under treatment he became dissatisfied, as there seemed to be 
no improvement in his condition, and, giving up all hope of 
cure, be travelled in different parts of Europe until 1861, when 
he returned to J^ew York. From July, 1860, to 1868, he was 
in a nearly helpless state, and was only able to get about with 
the assistance of a strong cane, and even then with great exer- 
tion. During the year 1867 he had a very severe attack of 
acute pain, limited to the lumbar region of the spine, and at- 
tended with violent spasms of the muscles of the back, which 
recurred at intervals for the period of four days, and were ex- 
cited by the least movement on his part. He now recalls 
similar seizures which had taken place at intervals a long time 
ago, but they were not so intense in character. In 1868, under 
a tonic treatment, he began to improve in walking, and on 
admission to the Out-door Department of the Xew Tork 
State Hospital for Diseases of the Xervous System, August 
16, 1870, he was in the following condition : 

"His right leg is not very much atrophied, while his left 
appears to be very well nourished. The muscles of the left 
leg respond very well to the induced current, while those of the 
right are not affected at all by it. The extensor muscles of the 
right leg are so greatly paralyzed that the patient is unable 
to raise the toe, and in consequence drags it along on the 
ground at every step. The right leg only seems to be involved, 



SPI^STAL PAEALYSIS. 27 

jet there is difficulty in guiding tlie movement of the left, not 
on account of the want of motor power, but from the absence 
of muscular sensibility to direct it. Under these circumstances 
it is with great difficulty that he can get about, even with the 
assistance of his cane, and, as he walks, his right leg bends 
under him, giving it the appearance of being shorter than the 
left, while he hastens forward as ftist as possible in order to 
maintain his equilibrium. The tactile sensibility is dimin- 
ished on the left side, as shown by the asthesiometer, as high 
as the umbilicus, and exactly limited to that side. The sen- 
sibility to pain, to the electric current, and deep pressure, is 
impaired on the left side, while the sensation of tickling is un- 
felt. Differences of temperature are immediately detected in 
both legs. He cannot stand with his eyes closed, and cannot 
walk at all in the dark. The impairment of motility is con- 
fined exclusively to the right leg. The heart, lungs, and kid- 
neys, are apparently healthy. There is incontinence of urine, 
with continual dribbling ; the urine is very alkaline ; the bow- 
els are constipated ; there is no stricture of the urethra, but 
atony of the bladder, with loss of sensibility of its mucous 
membrane. There is no pain in the back by pressure or per- 
cussion ; heat or cold does not produce any burning sensations 
in any part of the spine; there is no feeling of constriction 
or band around the waist ; there are no referred sensations 
whatever ; there are no spasms in the legs. There has been 
no rapid nor gradual extension of the paralysis upward. There 
has been no sympathetic affection of the eyes." 

'' The treatment in this case has been a teaspoonful of 
Squibb's fluid extract of ergot, with fifteen drops of the 
tincture of belladonna, three times a day internally, and the 
application of the primary galvanic current to the paralyzed 
muscles every alternate day. From August 16th to October 
5th his urine continued alkaline ; it was examined very often, 
that passed on rising in the morning being the specimen gen- 
erally tested. In order that no doubt should arise in regard 
to its reaction, his bladder was on several different occasions 
carefully syringed out, and the urine was then tested and found 
to be alkaline as soon as it was excreted from the kidneys. 
October Qth. — The urine was neutral, and on the 10th re- 



28 CLIl^ICAL LECTURES. 

markably acid, and it has continued, acid up to the present time, 
l^ovember 21, 1870, although the patient is living under ex 
actly similar circumstances as regards food and medicine. Oc- 
tober V)th. — He passed a good, full stream, and did not drib- 
ble, owing to the beneficial eflect of the belladonna. At this 
date the induced current, producing contractions in the right 
leg, was substituted for the primary galvanic. He has taken 
the fluid extract of ergot uninterruptedly up to the present 
time, but he ceased taking the tincture of belladonna. Octo- 
her ISth. — This patient has improved very much in walking 
since he first came under observation. He can at present 
move about quite readily without a cane, yet the right leg is 
still weak, and the toe occasionally catches as he walks. His 
gait is characterized by a peculiar manner of limping. The 
paralyzed muscles have considerably recovered their contrac- 
tility, and respond beautifully to a weak Faradaic current. 
The urine does not dribble away, yet there is a desire to pass 
it more frequently than is natural. The legs are both well 
nourished, and measurement shows no difference in their cir- 
cumference. Tactile sensibility, sensibility to pain, deep press- 
ure, tickling, and the electric current, are now only very 
slightly diminished in the left lower extremity. There is no 
perceptible retardation in the transmission of sensitive impres- 
sions on either side, although there was on the left at the time 
of his admission." 

N^ow, gentlemen, you have here three examples of organic 
disease of the spinal cord, giving rise to paraplegia, as it is 
called. Paraplegia is sometimes spoken of as a disease, but I 
wish you to understand that it is merely a symptom of a dis- 
eased condition, existing most generally in the spinal cord, but 
by no means invariably. The fault may lie with the sciatic 
nerves, for example. You will readily see that, if both of these 
nerves should happen to be cut, there would be paralysis of 
both legs, or one form of paraplegia. Cases also are on record 
in which it has been caused by cerebral disease. Paraplegia is, 
therefore, but a symptom of some lesion of the nervous system, 
producing paralysis below the point of injury or disease, and 
we form our ideas of the situation accoi'ding to the muscles. 



SPIIS^AL PAEALYSIS. 29 

and other parts of the bodj which are affected. Thus, some- 
times the lower extremities alone are paralyzed ; sometimes 
thej and the bladder or its sphincter are involved ; some- 
times the upper extremities participate, and so on. 

Among the affections of the spinal cord, commonly known 
as organic, there are three frequently met with, to which we 
shall confine our attention to-day, which have several points in 
common, and which at times are difficult to distinguish from 
each other. The first of tlie three is congestion of the vessels 
of the cord or its membranes ; the second, inflammation of the 
membranes — spinal meningitis ; the third, inflammation of the 
cord itself — myelitis. The cases before you illustrate two of 
these conditions : the first patient is in all probability suffer- 
ing from congestion of the spinal cord ; the second and third 
from myelitis. It is not always easy to distinguish between 
the two affections ; indeed, it is probably impossible, in some 
instances, to say whether we have to deal with a severe attack 
of congestion of the cord, or a mild one of myelitis ; though, as 
between slight congestion and severe myelitis, no doubt could 
arise. The rules of diagnosis laid down in the books serve 
well enough for typical cases, but will be found insufficient 
and unsatisfactory in the majority of those which come under 
your notice. 

In Eose Peyton's case, you observe there is no sense of con- 
striction around the abdomen. This sensation of " a cord around 
the waist" is considered a pathognomonic symptom of inflam- 
mation of the medulla, but the idea is not strictly correct. I 
have fomid the symptom in cases of very bad congestion, and 
I think also in one case of simple irritation of the cord. It is 
true, however, that the sensation is felt in almost every case 
of inflammation of the cord. It is probably due to muscular 
spasm ; and it indicates the upper limit of the paralysis. In 
some cases where the sciatic nerve is affected, and there is no 
trouble whatever with the spinal cord, we have a similar sense 
of constriction in the thigh, as if the limb were encased in 
armor. It is seen, not very rarely, in certain cases of sciatica, 
attended with loss of power. 

You observe, too, another point. This patient has had no 
spasms or twitchings of the limbs, none of those aberrations of 



30 CLESriCAL LECTUEES. 

motion so exceedingly common in myelitis. These s]3asmodic 
twitchings indicate irritation of the gray substance of the cord ; 
or rather, whenever you see them you may be very certain 
that the gray matter is in some way involved ; and it is not 
likely to be involved in congestion, unless this should become 
extreme, and enlarge the vessels to so great an extent as to 
exert very considerable compression upon the cord-substance. 
The twitchings depend strictly upon irritation of the gray 
matter ; and this ordinarily happens only when the cord is in- 
flamed, or subjected to pressure. 

The woman has had trouble with her urine. This you find 
in all three conditions— congestion, meningitis, myelitis. In 
the last you are more apt to have retention ; in the first, incon- 
tinence ; but you may have both in either condition. Incon- 
tinence depends simply upon paralysis of the sphincter of the 
bladder, retention upon paralysis of the bladder itself. The 
bladder, as you know, is a hollow muscle deriving its nervous 
supply from the spinal cord, and the act of urination is due to 
its contraction, the sphincter being at the same time relaxed. 
If the cord is inflamed, or otherwise disordered at or above 
the point wdiere the vesical nerves are given ofl", we shall have 
paralysis of one or the other of these sets of muscular fibres, or 
of both ; for we may have both paralyzed together, the patient 
being unable either to retain his water or to expel it com- 
pletely, and then the urine dribbles slowly oif. 

You find alkalinity of the urine laid down as one of the 
signs pathognomonic of myelitis ; yet, in the case of White, the 
urine is markedly acid, although I have no doubt that he is 
suffering from inflammation of the cord, mainly of its pos- 
terior columns. The sign is therefore not invariably present, 
but it is very frequently. It may be that this patient will 
have alkaline urine by-and-by. The present acidity may per- 
haps be due to something in his diet. If a myelitic subject 
were taking mineral acids, for instance, they would be pretty 
sure to acidulate the urine. In another case which has been 
shown you, and which is now in hospital, of myelitis, com- 
plicated with cerebral paralysis, the urine is very decidedly 
alkaline. It may happen that the urine is found alkaline 
when the cord is perfectly sound, the alkalinity depending 



SPINAL PAEALYSIS. 31 

directly upon paralysis of the bladder (or upon any other 
affection, as enlarged prostate, which prevents its complete 
evacnation). The small portion of urine remaining in the 
bladder after each act of micturition becomes decomposed ; 
and by contact with this and with the vesical mucus, the nor- 
mal urine, as it enters the bladder, is also speedily decom- 
posed and rendered alkaline. But in myelitis the urine is 
secreted by the kidneys in an alkaline condition, and it is tliis 
wliich is the diagnostic featm^e. To make a proper examina- 
tion in case of doubt, the bladder must be thoroughly evacu- 
ated, and well washed out with lukewarm water slightly 
acidulated, and then the first urine that flows must be taken 
for testing. 

Ill the case of Baxter this coarse was pursued, and the fact 
was demonstrated that the marked alkalinity observed was an 
inherent quality of the urine as excreted by the kidneys. 
IS^either White nor Baxter can stand with his eyes' shut and 
his feet close together, and neither can walk in the dark. 
The text-books speak of these symptoms as absolutely diagnos- 
tic of locomotor ataxia, which is nothing more than myelitis 
affecting the posterior columns of the cord. The inflamma- 
tory condition subsequently degenerates into what is termed 
sclerosis, or hardening of the posterior columns. It used to 
be thought that locomotor ataxia was an affection of the cere- 
bellum ; but no one at all conversant with the recent advances 
in its pathology now holds that view. It is simply inflamma- 
tion of the posterior columns. But this inability to stand or 
to walk without the aid of sight, is not indicative of any par- 
ticular trouble of the cord, as until recently supposed ; it 
merely indicates a want of sensibility in the soles of the feet, 
and may depend upon an affection of the nerves as well as 
upon a central lesion. The sense of pressure is also much 
diminished in these cases, and, with this double insensi- 
bility, the patient requires all the help of his eyes and ears 
to get along. By looking at his feet, or at the ground a little 
in front of them, he can jud^e of their position, and manage to 
walk pretty well ; but the moment he shuts his eyes, he does 
not know where his feet are, and so he falls. This is the 
reason, then, that a person having any disease of the posterior 



32 CLINICAL LECTURES. 

columns of the spinal cord, involving their integrity, or any 
other affection causing loss of sensibility in the soles of the 
feet, and loss of the sense of pressure, cannot stand or walk in 
the dark ; he has nothing to guide his muscular sense. 

There is anotlier point in Baxter's case which is exceedingly 
interesting. You will recollect that it is stated, in the history 
I have just read, that sensibility is impaired in the left leg, the 
motility being unimpaired, while motility is diminished in 
the right leg, the sensibility being unaffected. IN^ow, if you 
will recall your anatomical and physiological knowledge, you 
will recollect that the sensory roots of the spinal nerves are in 
the posterior columns, and that they decussate soon after en- 
tering, and that the motor roots are in the anterior colmnns 
and do not decussate till they reach the lower part of the me- 
dulla oblongata. It follows therefore that in Baxter one lateral 
half only of the cord is involved, and the symptoms show that 
this is the right half, including the anterior and posterior col- 
umns of that side. 

I had recently a patient affected with locomotor ataxia, 
living at the Fifth Avenue Hotel. He was able to walk quite 
w^ell along the sidewalk, but he felt the greatest apprehension 
at crossing the street. This showed the loss of self-confidence 
which is strongly characteristic of these patients. They are 
indisposed to attempt any little gymnastic exercises which once 
they would have essayed without hesitation — though to cross 
Broadway through a jam of vehicles might be said to be a 
gymnastic feat that would tax the best of us. I once watched 
this gentleman for fully fifteen minutes trying to make up his 
mind to go across. He could not do it, though there were 
during the time many openings, when, but for this want of 
confidence, he might have crossed with ease. On one occasion, 
coming down-stairs at the hotel, he did tolerably well until he 
got to the bottom step ; then, putting his foot upon the marble 
pavement, he became suddenly alarmed at its slippery char- 
acter ; fell upon his hands and knees, and called aloud for 
help. I have often seen these patients, while crossing my own 
hall-floor, suddenly stop and settle down into a sitting posture. 
This lack of confidence, which is so marked a characteristic 



SPINAL PAEALYSIS. 38 

of the ataxic patient, lias not, so far as I am aware, been men- 
tioned by any writer npon the subject. 

Aneesthesia is met with both in inflammation and in conges- 
tion of the spinal cord, though I think more frequently in inflam- 
mation than in congestion ; and you find it in both of the cases 
we have been examining. You may also have hypersesthesia 
in these afi*ections. After a time, if the inflammatory process 
goes on unchecked, these sensations cease ; they cease, too, it 
the patient is getting cured. In the former case, as the disease 
Sidysinces>,ramolUsseme7it, or softening of the cord, takes place, 
and it is no longer capable either of giving rise to, or of com- 
municating, any sensation ; the feeling of numbness, therefore, 
disappears, and with it goes the twitching of the muscles. In 
treating cases of myelitis, then, you must be on your guard 
against misinterpreting this into an evidence of convalescence 
when the patient is really getting worse. The other symp- 
toms will, of course, settle the point. 

It very generally happens, in cases of meningitis especially, 
that a prominent symptom, which may be regarded as quite 
characteristic, is the permanent tonic contraction of the flexor 
muscles of the limbs. In extreme cases, the heel is drawn up 
so as to touch the buttock, and the knee so as to touch the 
chin ; more commonly, however, the flexion is not thus com- 
plete. I have seen a number of these cases, and have had 
several recently under my care. One of them, a very prom- 
inent merchant, in Grand Street, came to me about a year 
ago, with such violent contraction of the limbs that the leg 
was exactly parallel to the thigh, and the thigh bent npon the 
chest, the heels against the glutsei, the chin resting on the 
knees. When I first saw him he had been in that position 
for several weeks. In another very severe case, that of a gen- 
tleman from Ohio, the same position of extreme flexion had 
been maintained for several years. I succeeded in curing the 
disease entirely, but it was impossible to bring down the legs. 
The muscles, from long contraction, had become so shortened, 
that no reasonable degree of force could overcome their re- 
sistance. So I called in my friend Prof. Sayre, who cut the 
tendons of the gastrocnemii, of the ilisei, of the tensores vagi- 
narum femorum, and some others, and then forciblv stretched 



34 CLIiaCAL LECTUEES. 

out the limbs. Even the skin had become so contracted that 
by this extension it was ruptured in the popliteal space, 
making a gap three inches wide. But, in spite of all this, the 
limbs would not stay down. The patient could not bear the 
fatigue of having them stretched by the weights which were 
applied, and the attempt had to be given up. 

In that form of myelitis involving the posterior columns 
of the cord, it often happens that one of the first symptoms 
noticed is some disturbance of vision ; generally that the pa- 
tient sees double. This is due to paralysis of some of the 
orbital muscles. There may be simple ptosis, from paralysis of 
the levator palpebrse superioris ; but m.ore commonly some of 
the muscles which move the eyeball are affected, and double 
vision necessarily results. This symptom often comes on early, 
and then soon disappears. It is dependent upon the intimate 
connection between the spinal cord, the sympathetic nerve, 
and the muscles moving the eyeball — the sympathetic having 
connection with every spinal nerve, and transmitting the abnor- 
mal influences thence derived to the muscles. So with all the 
head-symptoms which we find in this disease — and they are 
often very grave ; I have seen cases approaching idiocy — they 
all result from the effect on the brain of the connection of the 
sympathetic nerve with the diseased spinal cord. 

Before pursuing this subject further, let me present to you 
this patient who has just come in, and of whose case we have 
no written history. The gentleman, Mr. Atkin, is a teacher, 
about forty-five years of age. It seems that he served in the 
army ; at Petersburg was much exposed to the weather ; had 
an attack of fever of some sort, attended with great exhaus- 
tion ; and when he recovered found that he had to a great ex- 
tent lost power over his legs. He now walks with much difii- 
culty, and in a cursory view you would probably observe no 
marked difference between his gait and that of White, although 
there is a difference which study of the subject would lead 
you to notice. From the examination I have been able to 
make, I cannot discover that he has any organic disease of the 
cord. He is probably suffering from what is called reflex pa- 
ralysis, an affection which may result from trouble of the blad- 
der^ from worms in the intestinal canal, from diphtheria, ty- 



SPINAL PARALYSIS. 35 

plioid fever, and probably various other diseased conditions. 
It is most likely immediately dependent npon a deficiency of 
blood in the cord, though this point is not yet settled. In 
that case the aiisemia of the cord may be due to disorder of 
the sympathetic nerve. The name reflex paralysis is a bad 
one, but it is in common use, and I will not burden your 
memory with any other. This patient has no muscular twitch- 
ing?, no anaesthesia or numbness, no loss of power, no diffi- 
culty with his urine, no sensation of constriction aboiit the 
belly. These are in brief the characteristic marks of reflex 
paralysis — they are simply negative. The diagnosis depends 
upon the absence of the symptoms of the organic affections 
which I have brought before you. 

Too often, from fixing attention on the single symptom of 
loss of motive power, these diverse aflfections — myelitis, menin- 
gitis, congestion, reflex paralysis — are confounded with each 
other, all mixed up in the so-called disease, paraplegia. How 
great the distinction is you will at once understand. In this 
last case there is no serious trouble of the cord, nothing which 
cannot almost certainly be cured. In the other cases, although 
there is a very strong probability that these particular patients 
will get well, the prognosis is by no means so favorable. In 
organic lesion, those who get well out of a hundred can be 
counted on the fingers of one hand ; in reflex paralysis, ninety- 
nine out of one hundred recover. 

I have said enough to indicate the main principles v/hich 
should guide you in your diagnosis of these forms of paralysis, 
and have given a slight idea of the prognosis. We come now^ to 
the treatment. And here there is the utmost possible difference 
in the management of the two categories of paraplegic affec- 
tions. In the organic lesions myelitis and meningitis (as well 
as in congestion) the indications are to diminish the irritability 
of the cord, and to lessen the amount of blood in it ; in 
reflex paralysis, on the other hand, the indication is to in- 
crease its excitability, and to this end its blood-supply. Now, 
if you institute a given treatment for paraplegia, and apply it 
indifferently to the two classes of cases, you will be quite as 
likely to harm as to help your patients — indeed, you may do 
them irreparable damage. 



36 CLIIS^ICAL LECTUEES. 

It is a fortunate thing that the treatment of myelitis, me- 
ningitis, and congestion, is essentially the same, so that even 
where yon are in doubt regarding the diagnosis, as between 
these, you need not hesitate as to your principles of action. 
The measures of treatment may be divided into tlie external 
and the internal. 

Of the external means I give the first place to dry cups, 
applied every night, or every alternate night, on either side of 
the spine. Blisters I have long since given up, as I think they 
only do harm. The cupping tends, of course, to divert the 
blood from the cord to the superficial vessels. 

Another means of abstracting blood from the cord was 
brought prominently to my notice by the case of the Grand 
Street merchant before mentioned. He had in years past 
suffered much from bleeding piles, which had been oper- 
ated upon and cured. At about the turning-point of my 
treatment of the case, the piles reappeared. One night they 
bled profusely, and the next morning I found the patient 
very much better. He had had no twitchings in the legs dur- 
ing the night, and had not been compelled to tie them to the 
foot-posts of the bed — a proceeding which had till then been 
necessary to prevent their getting drawn up to his chin before 
morning. The pain in the cord, too, had greatly diminished, 
and he had gained considerably more power over the bladder. 
Acting upon this hint, I applied a number of leeches to the 
verge of the anus, and kept on leeching him thus about once 
a week, with the greatest possible benefit. I ai'terward found 
two cases on record where congestion of the cord had appar- 
ently been cured by profuse hsemorrhoidal discharges. I have 
since very frequently in these cases employed leeching at the 
margin of the anus, in addition to the dry cups over the spine, 
and I recommend it as a valuable part of the treatment. 

Another excellent revulsive means is the alternate applica- 
tion of heat and cold over the spine. Take a lump of ice and 
wrap it in a thin towel so as to hold it, and have at hand a 
basin of hot water and a sponge. First draw the ice three or 
four times down the spine ; then do the same with the sponge 
of hot water ; and so on alternately for five or six minutes. 
Do this every night or every morning, as most convenient. 



SPIIS^AL PARALYSIS. 37 

Bv this means tlie skin becomes v^eiy red ; the irritability of 
the cord is much lessened ; and there is almost always effected 
a very marked alleviation of the symptoms. 

The only fm*ther external means of treatment which I have 
found useful, is the application of galvanism to the spinal col- 
umn. I place the positive pole above, the negative pole below, 
thus passing the current from above downward, and let it 
flow about five minutes, at the longest. The induced current, 
also, is of great value, not in curing the spinal affection itself, 
but in counteracting its effects upon the muscles. In the his- 
tory of Rose Peyton you find it mentioned that the muscles of 
the legs are greatly atrophied. This atrophy is very common, 
depending on disuse of the muscles and insufficient nervous 
supply to keep up full nutrition. By persistent faradization 
you may restore these w^asted muscles nearly or quite to their 
normal size and functional power, thus putting them in condi- 
tion to respond to their proper nervous stimulus, if you should 
succeed in restoring that. 

Of the internal means of treatment there is little to be said. 
There are only two or three medicines that are really of use. 
The first of these is ergot, in large doses. I have commonly 
used either ^Neergaard's tincture, or Squibb's fluid extract; 
but of late I have taken to using the drug in substance freshly 
powdered, and I think it acts, perhaps, better in some cases 
than either of the preparations I have named. Of the fluid 
extract I give about one fluidrachm three times a day. This 
dose is said to be equivalent to about one hundred grains of 
the powder, but this must be a mistake ; for I find practically 
that I get about as much effect from thirty grains of the pow- 
der as from a fluidrachm of Squibb's extract. I give these 
large doses because the small ones of the text-books have no 
appreciable effect. You will sometimes be warned by drug- 
gists, who know nothing about the matter, and by physicians, 
who ought to know something about it, that such doses will 
cause gangrene. !Now I suppose there is not a single authentic 
case on record of gangrene resulting simply from the use of 
ergot. Gangrene occurs, it is true, in those countries where 
ergotized rye is used as food ; but it is due not to the presence 
of ergot, but to the absence of fresh meat and almost every 



38 CLimCAL LECTUEES. 

thing else from the dietary of the poorer classes; it is the 
result of starvation. I have talked with those who have lived 
in those countries, and they say that the stories of ergot- poi- 
soning are wholly the result of sensationalism or of ignorance, 
and can never be traced to any trustworthy observation. My 
friend Dr. Jacobi, formerly resident in such a region, pro- 
nounces the accounts all a fabrication. You may, then, safely 
give of the fluid extract, or the tincture, doses of one or two 
fluidrachms, the latter being the highest I have ever given. 
Of the freshly-prepared powder, the highest dose I have given 
is sixty grains ; you may usually give it in twenty- or thirty- 
grain doses tliree times a day. There is no other one remedy 
so useful as ergot in these inflammatory or congestive afi'ec- 
tions of the cord or its membranes ; and, as soon as you have 
determined that you have such an afi'ection, you should give 
it at once, without fail and without hesitation. 

- Another useful drug is the iodide of potassium, which I also 
give in large doses. If, as is not rarely the case, there be any 
syphilitic taint, this may be combined with the bichloride of 
mercury in doses of one-sixteenth of a grain. The iodide I 
commonly give in commencing doses of seven grains three 
times a day, increasing each dose by one grain daily until I 
reach, say, forty-five grains three times a day. The most con- 
venient mode is to make a saturated solution in water, con- 
taining a grain to the drop, and then measure the dose by 
drops. In the case of the gentleman from Ohio with contracted 
limbs, I got as high as sixty-drop doses before I stopped, and, 
as the patient had syphilitic infection, I used also the bi- 
chloride of mercury. 

Belladonna has been strongly recommended for these afi'ec- 
tions, especially by Brown-Sequard. I have never found it of 
service, except in those cases where there was paralysis of the 
sphincter of the bladder ; there, however, it is of great value. 
You may give the tincture in the dose of twenty drops three 
times a day. By a mistake of mine, a patient with paralysis of 
the vesical sphincter took in one day three doses of a flui- 
drachm each. It efi'ectually closed up his bladder, so that he 
needed something to open it ; but I would not advise you to 
repeat this dose, for it also produced the toxic effects of the 
drug. 



LEAD PARALYSIS. 39 

Xitrate of silver is used principally where there is disease 
of the posterior cohimns of the cord. It is best given in pill, 
in doses of one-fourth of a grain three times a day, and must be 
continued for three or four weeks before you can tell wliether 
it is doing good or not. 

These are the chief means of treatment for the congestive 
and inflammatory affections of the spinal cord. How, now, 
shall we treat reflex paralysis ? As I have before said, upon 
just the opposite principle. Our main reliance is upon strych- 
nia, which increases the irritability of the cord, especially of 
its anterior columns, increases its circulation, and improves 
its nutrition. It is far best given hypodermically, a daily in- 
jection of one-thirty-second of a grain, under the skin, will do 
as much good as at least three times that amount given by the 
mouth. Of course, if you give strychnia to your congestive 
and inflammatory paraplegics yon will only make them worse. 
In these it is productive of good only at a certain late stage of 
the disease, when the cure is pretty much assured, and we 
wish to improve the nutrition of the cord; and even then it 
must be given in small doses, say one-sixty-fourth of a grain, 
and carefully guarded by ergot. I think it is also allowable to 
employ it as a means of diagnosis when you first take hold of a 
doubtful case. A hypodermic injection of one-twenty-fifth of 
a grain will soon settle the question whether you have to deal 
with a reflex or an inflammatory paralysis. If the former, the 
patient will be helped by the experiment ; if the latter, he 
will find all his symptoms aggravated, but there is little prob- 
ability of any serious injury from the single dose, and you 
have thereafter your course of treatment clear. 



LECTUEE lY.^ 

LEAD-PAKALYSIS — CHOREA. 

The first case which comes before us to-day is one of lead- 
palsy, and the following is its history, as prepared by Dr. 
Cross : 

Paralysis from Lead-poisoning. — '^Michael Cofly, aged 
thirty-two years, single, born in Ireland, a painter by occu- 
pation. 

^ Reported phonographicallj by Dr. John Winslow. 



40 CLIlSnCAL LECTUEES. 

" When a young man, had soft chancres and buboes, but 
gives no well-defined, rational symptoms of syphilis. He has 
been moderately temperate in his habits, and bas always 
enjoyed very good health until 1863, when he was suddenly 
seized with a very severe attack of colic, which was preceded 
by great constipation of the bowels and loss of appetite. There 
soon succeeded nausea and vomiting of bile, accompanied by 
an acute lancinating pain in the epigastric region, which was 
so severe that the j)atient was obliged to lie flat on the floor, 
and press his abdomen strongly against that surface in order 
to obtain temporary relief. 

" These symptoms continued off and on for a period of about 
two weeks, gradually diminishing in severity, however, espe- 
cially after an evacuation from the rectum, which was only 
obtained with the greatest difficulty. Subsequently the pa- 
tient had cold, clammy perspirations, and was much debili- 
tated ; his right leg at this time became very oedematous. In 
the course of two months he resumed his usual avocation, that 
of a painter, but was not aware at this time that his sickness 
had been caused by the action of lead. During the year 1867 
his bowels again became very costive, and his stools, which 
consisted of only a few lumps of dry, hardened faeces, were at- 
tended with much pain and straiuing. Soon there followed a 
second attack much more severe than the flrst, which was 
characterized by nearly similar symptoms, only there was 
superadded great tenderness over the kidneys, which were so 
sensitive that the least pressure caused him the most intense 
agony. The urine was very scanty and high-colored, and there 
was a well-marked blue discoloration of the gums. 

" In a few months, having somewiiat recovered, he went to 
work again at his former occupation, which he pursued un- 
interruptedly until the 25th of December, 1869, when, after 
having passed a very uncomfortable day, his former symptoms 
returned with increased violence, while the paroxysms of colic 
came on at much shorter intervals than they had done in the 
preceding seizures; in fact, instead of intermissions as for- 
merly, there were only remissions of the intestinal spasm. 
For the first time, he had pain in the feet and the inside of his 



LEAD PARALYSIS. 41 

tliiglis. The urine was more scanty and higher-colored, and 
the bowels more constipated than before. 

" In three weeks he again began to work, and had no more 
trouble except constipation of the bowels, and weakness in 
both his upper and lower extremities, until July, 18T0, when 
he lost his appetite, and felt very weary and exhausted after 
any small amount of exertion. He was very restless and 
could not sleep at night, and this inability to sleep was a 
sequela of all the other seizures. Now came great tremor of 
the right hand and arm, which was soon followed by tremor 
in the left. In August, 1870, he had his fourth and last at- 
tack, which was the most severe of all, and lasted about two 
weeks. Tliis time he vomited blood, had acute pains in the 
soles of the feet, and cramps in the right hand. 

" On recovering from the immediate effects of the colic, he 
found that he was unable to use his arm or hand at all, and 
that he had lost power in his legs also. Soon after this he 
was admitted to the Charity Hospital, where he remained for 
a fortnio-ht, and durino^ his residence in that institution he be- 
came delirious, and continued so for about eighteen hours. 

"He came to the Out-door Department of the New York 
State Hospital for Diseases of the Nervous System, September 
12, 1870, when his condition was as follows : 

" There was the characteristic dropping of both wrists, which 
was very extreme in degree. The paralysis of the supinator 
and extensor muscles of both upper extremities vfas exceed- 
ingly well marked ; the flexors were also involved, only to a 
much more limited extent. The paralysis was more consid- 
erable in the right and forearm and hand than in the left. 
There was much atrophy of all the muscles of these parts, 
and this was very conspicuous in the abductors and adduc- 
tors of the thumbs. The patient was so weak in his lower 
extremities, that he was unable to arise from the sitting pos- 
ture without assistance, and as he walked he tottered at every 
step. Yet, he did not drag the toe of either foot, nor swing 
his legs, as do those suffering from hemiplegia. The blue line 
was very plainly seen around the edge of the gums of the 
upper and lower jaw. On testing the amount of muscular 
power in the right hand by means of the dynamometer, he was 



42 CLIIS-ICAL LECTUEE3. 

able to turn the indicator only 10°, wMle with the left he could 
accomplish somewhat more. The tactile sensibility, sensibility 
to the electric current, and to pain, were very greatly dimin- 
ished. The temperature was also diminished ; muscular con- 
tractility was so much impaired that a powerful induced 
current had not the slio;htest effect in causing^ contractions, 
and even when the primary galvanic current (sixty cells and 
very strong) was used the muscles ouly responded very feebly, 
if we except perhaps the flexors, so almost completely had 
then' irritability been destroyed. The bowels were regular, 
the urine was normal, and, although no chemical analysis for 
lead was made, undoubtedly it would have been found. 

" The appearance of the patient was anoemic, cachectic, and 
depressed ; the breath was very off'ansive ; the retinaB were 
anaemic ; the lungs were healthy, and so was the heart, except- 
ing an inorganic murmur at its base." 

[Note. — The treatment in this case has consisted of the 
internal administration of the iodide of potassium, commen- 
cing with ten-grain doses three times a day, and the daily 
application of the primary galvanic current to the paralyzed 
muscles, with a hypodermic injection of the thirty-second of a 
grain of the sulphate of strychnia every day. 

Sejyteniber 17th. — The iodide was increased to fifteen grains 
three times a day. 

Sej)terii^jer 2Uh. — Slight fibrillary contractions in the right 
arm were produced to-day for the first time, by means of the 
Faraiaic current. October 1st. — The iodide of potassium was 
increased to twenty grains three times a day. October hth. — 
The induced current had just commenced to cause slight con- 
tractions in the left forearm. 

Hovemher loth. — Faradization of the left forearm pro- 
duced good contractions in the extensor corpi radialis and 
ulnarius muscles. The blue line having disappeared, the 
iodide of potassium was discontinued, and a tonic substituted. 

JVovember 2Sd. — The muscles of both arms respond feebly 
to the induced current, yet by means of it the hands can 
now be extended nearly on a level with the forearms. The 
right arm has improved the more. Sensibility to touch and 
to electricity has much improved. His bowels are regular, 



LEAD PAEALYSIS. 43 

lie sleeps well, and liis appetite is good. The power in both 
hands has much increased, and he is able to work every day, 
although he is still nnder treatment. — T. M. B. C] 

On a former occasion I gave yon some idea of the phe- 
nomena attending paralysis from lead-poisoning; and in my 
remarks upon the application of electricity to the treatment of 
diseases of the nervous system I called your special attention 
to its efficacy in this disease. 

The pathology of the affection is not very clearly under- 
stood. One theory is, that the paralysis is due to the lead 
beino' brous^ht into actual contact with the muscles, and de- 
posited in their tissue. There might seem to be something to 
bear out this idea, in the fact that the loss of power is com- 
monly greatest in the right hand and arm, which, in the case 
of painters and other workers in lead, are probably more 
exposed than the left to contact with the metal. But to this 
an opposing argument, which, I think, cannot be overturned, 
is presented by the fact that some of the worst cases of lead- 
paralysis are due to the use of saturnine cosmetics ; and yet in 
tliese cases, just as with the painters, etc., it is the extensors, 
generally those of the upper extremities, that suffer. 

An aggravated instance of this kind I lately saw in consul- 
tation with Dr. Sayre, in the case of a lady from Kansas, who 
had for a long time been accustomed to apply '' Laird's bloom 
of youth" to the face and neck. J^Tow it stands to reason that 
if the paralysis were due to the contact of the lead with the 
muscles, it should have affected chiefly those of the face and 
neck; but of this there was no sign. Take another example. 
I was consulted regarding a lady in Connecticut, who had 
paralysis strictly confined to the extensors of the wrists. I 
found that she, too, had been accustomed to the use of a lead- 
cosmetic, and also that the drinking-water was conveyed a 
long distance to the house through a lead pipe. 

It cannot be, then, that the paralysis affects by preference 
the muscles of the hands and arms, simply because the hands 
are more exposed to contact Avith lead. Indeed, if that were 
the case, we should expect the flexors to be paralyzed rather 
than the extensors, for it is the palms of the hands that do the 



44 CLINICAL LECTURES. 

handling. All we know of tlie matter is, that lead, introduced 
into tlie system by whatever channel, will produce, in some 
unexplained manner, a certain train of symptoms, among 
them lead-colic, which is probably only spasm of the intestinal 
muscles, and paralysis of the extensors of the arms and hands, 
and in extreme cases also of those of the lower extremities. 

The only form of lead capable of producing these toxic effects 
would seem to be the carbonate. Metallic lead may appear 
to do so, but that is probably because it is so readily oxidized, 
and then converted into the carbonate. I do not think that 
the acetate is poisonous as such, yet some persons have been 
poisoned by taking it in large amount — a result probably due 
to its change into the carbonate in the alimentary canal. 

Lead linds various avenues of access to the system, as you 
have already inferred. It may enter by the skin, the lungs, or 
the alimentary canal. Its effects are most frequently seen in 
Dainters, who handle its oxide and carbonate, and probably 
also inhale more or less of them. Lead, as you know, is the 
basis of nearly all our paints, zinc taking its place only for cer- 
tain in-door decorations not required to stand the weather. 
J^ext in frequency among its victims come the workers in 
metallic lead. I have seen a number among the shot-makers? 
and the makers of bar-lead ; and I have already brought before 
you two cases of this paralysis in type-setters. Lead-miners 
are very apt to suffer, and so are lead-smelters, who breathe its 
fumes. 

For water to become poisonous by being brought through 
leaden pipes, or by standing in leaden reservoirs, it is ne- 
cessary that it should be quite pure. In that case it will 
readily become impregnated with lead, and its use for drinking 
or cooking may be very dangerous. Some years ago I lived in 
a house where the washing-water was supplied from a lead- 
lined cistern, filled by rain-water from the roof. I made fre- 
quent analyses of this water, and sometimes it contained as 
much as43i^gr3. of lead to the gallon. On a clear day I could 
even see the little metallic particles floating about in a pre- 
cipitating-glass. This, bear in mind, was rain-water, and so, 
very pure. But with ordinary spring or river water there is 
comparatively little danger, unless it be allowed to stand a 



LEAD PARALYSIS. 45 

long time in the pipes. For the generality of sucli water con- 
tains salts, especially sulphates, which form with the lead an 
insoluble coating for the inside of the tube, protecting it from 
fiu-ther action. It is not safe, however, to rely upon this with- 
out an analysis of the water ; and in any case it is not safe to 
drink water that has been standing long in the pipes. In the 
case of the lady just mentioned, the water was brought to the 
house from a very pure spring, so pure that neither baryta- 
water nor nitrate of silver gave any precipitate of sulphate or 
chloride. 

In England, a few years ago, the family of the Prince 
de Joinville were all poisoned by lead, owing, as it was found, 
entirely to the water used, and which contained not one grain 
to the gallon. I have met with some similar cases in this city, 
but always from the use of w^ater that had remained long in 
the pipes — for the Croton is not so remarkably pure as to be- 
come dangerous when it is being constantly drawn. These 
cases have occurred mostly in persons employed about schools 
or factories, where the water would be standing unused over 
Sunday, and in the former over Saturday also. You know 
that ale and beer, when not drawn directly from the cask, are 
commonly conducted to the fountain through lead. I had a 
curious case of lead-poisoning, which for some time puzzled me, 
in the wife of the proprietor of a beer-saloon. There seemed 
to be no source of lead except the beer-pipe ; yet the family, 
which was German, all drank beer, and why should this mem- 
ber suffer and the others escape ? The mystery was solved on 
learning that it was her habit, every Monday morning w^hen 
she came down to open the saloon, to draw off first a couple of 
glasses for herself. In accordance with the excise law they 
sold no beer on Sunday, so that she got the full benefit of 
what lead the beer in the pipe would dissolve from Saturday 
night to Monday morning. It gave her lead-colic, and after- 
ward lead-palsy. 

Look, now, at the patient before you. Although he has im- 
proved under treatment, yet you see the characteristic " wrist- 
drop " very strongly marked. With the hand prone you ob- 
serve that it hangs down powerless; he cannot extend the 
hand so as to bring it on a line with the forearm. There is 



46 CLINICAL LECTURES. 

only a slight tremulous motion when he makes the effort. 
Even the strong induced current which I am now applying 
to the extensors on tlie right forearm, fails to make them con- 
tract. The flexors, too, are much enfeebled, although they 
respond slightly to the current, so that when I place one 
sponge on the front and the other on the back of the forearm, 
they flex the thumb and fingers a little ; for the extensors, 
though traversed by the current, cannot oppose them. All the 
other muscles, even those of the upper arm, have suffered from 
long disuse. I now pass the current directly through the 
biceps, and it comes up but partially and with difiiculty. 
'Now let us try the electrodes on the back of the left forearm. 
The extensors are not so badly off as on the right ; I can feel 
and see them rise up a little under the electric stimulus, but 
not enough to lift the hand. 

The loss of power in the flexor muscles of the fingers may 
be best exhibited by the little instrument I show you here — 
the dynamometer. It is simply an elliptic spring, of a size to 
be conveniently grasped by the hand, and having an index to 
show the amount of compression effected. It measures with 
the utmost accuracy the degree of grasping force. You see 
that this patient's greatest pressure sufiices only to move the 
index ten degrees ; it would hardly kill a fly ! You note also, 
from the position of the hand, that the flexor carpi ulnaris is 
more seriously paralyzed than the flexor radialis. This little 
piece of mechanism I commend to you as exceedingly useful. 
By no other means can you form so accurate an estimate of 
your patient's condition, or follow from day to day the almost 
imperceptible steps of his progress toward impro^'ement or 
the reverse. To tell the patient to squeeze your hand is a very 
crude method. You could not judge by it whether he was able 
to move this index fifteen or twenty-five degrees. Without 
the graphic attachment, the instrument is very cheap. This 
attachment — the dynamograph — which I now j)lace in posi- 
tion, is essentially the same that you have been longer familiar 
with in JVIarey's sphygmograph. The index of the dyna- 
mometer has a pencil afiixed to it, its point resting against a 
card laid upon this rectangular brass plate. By winding up 
a spring I set in operation a clock-work which moves the plate 



LEAD PAEALYSIS. 47 

and card along past the pencil-point at a perfectly uniform 
rate. If bj an nn varying degree of compression the index and 
pencil are held stationary, the latter will of course make a' 
straight mark upon the card ; but if the pressure varies, its ir- 
regularities will be faithfully recorded in corresponding irregu- 
larities of the trace. This tests, therefore, the patient's ability 
to maintain a continuous muscular contraction ; it shows, not 
only the strength of liis muscle, but the tone of his nerve. In 
certain cases of cerebral paralysis, as well as in some forms of 
spinal disease, its indications are of the utmost importance. 
Let us try it now upon the man we have been examining. 
The lever bearing the pencil starts at the height of ten degrees, 
the point, you remember, to which he raised it before; but it 
remains there hardly a moment. 'Now it is falling, falling 
steadily, and before the card has stopped passing, it has 
reached the bottom — the man's grasping power is utterly 
exhausted. Here you see a number of traces made by other 
patients — for I employ this instrument a great deal. In one 
set of them, made by a patient with cerebral paralysis, you 
note a marked difference between the early traces made by the 
right and by the left hand, and by following out the series 
you can watch beautifully the successive stages of improve- 
ment, until the lines become as straight as you or I could 
make them. 

The prognosis in lead-paralysis is always decidedly favor- 
able if you can get the muscles to respond at all to the induced 
current ; and it is still favorable, though more time must be 
allowed, if they will respond only to the primary current. But 
if no response can be evoked by as powerful a galvanic current 
as it is safe to apply, then you may as well give up the case. 
As examples of the time required for cure in reasonably favor- 
able cases, let me briefly cite a few from my case-book : 

1. X. T, — ^o contraction from induced current. Primary 
current caused powerful contractions. Cure in four months. 

2. W. C. — Yery feeble contraction from induced current. 
Primary current caused strong contraction. Atrophy of all 
the extensors of the wrist, and adductors of thumb. Cure in 
six months. 



48 CLINICAL LECTURES. 

3. J. B. H. — 1^0 action from powerful induced current. 
Primary current caused strong contractions in all the paralyzed 
muscles. Cure in two and a lialf months. 

4. W. J. — Lead-paralysis, the result of using cosmetic con- 
taining lead. Extensors of wrist aifected. No effect from 
strong induced current. Primary current induced strong con- 
tractions. Cure in three months and twenty days. 

6. M. P. — Cosmetic. No effect from strong induced cur- 
rent. Strong contractions from primary current. 

6. J. D., painter. — No effect from induced current. Strong 
contractions from primary current. Still under treatment. 

Y. C. N. — Contractions from induced current. Cure in 
six weeks. 

8. P. C. — No contractions from induced current. Strong 
contractions from primary current. Cure in two and a half 
months. 

In all these cases contractions were caused either by the 
induced or by the primary current, and I was therefore able 
to promise definitely that they would be cured. Where the 
affected muscles respond unmistakably, though feebly, to. the 
induced current, you may safely say that under proper treatment 
their functions will be restored in a couple of months. If they 
will not respond to that at first, but only to the more powerful 
primary current, then you must date your two months for re- 
covery from the time when Faradism begins to affect them. 
In the case before us, those muscles which you have seen con- 
tract under the Faradaic current will probably in two months 
longer respond normally to the stimulus of the will ; but some 
of them, like the adductors and abductors of the thumb, are so 
far atrophied that it will take much longer than that for their 
nutrition to become fully established and restore them to their 
old size and strength. 

The treatment has been already indicated in the history of 
this case. It is customary to begin it with the iodide of potas- 
sium, in order to eliminate the lead from the system ; and I 
generally keep up this medicine until the blue line completely 
disappears from the gums, for until that is gone you may be 
pretty sure there is some lead left. In this man's case you see 



CHOREA. 49 

it is fast going ; tlie bine line lias changed to a pale, whitish 
gray. The lead combines with the iodide to form a soluble 
salt, which is chieiij eliminated bj the kidneys. Yon may 
find lead in the nrine of these patients after giving the iodide 
of potassium. I give no other medicine than this, unless there 
be marked cachexia, when the patient may require tonics, such 
as quinine, iron, etc. For the rest you must have recourse to 
electricity. There is no way of treating these cases success- 
fully except by this, in one or other of its forms. You may 
have removed all the lead from the system, yet tbe patient can 
move his muscles no better than before. To restore them to 
use they must be exercised ; and to exercise them you must find 
a stimulus to wliich they will answer. This electricity aifords. 
But you must be sure that you apply it in a fo]'m which will 
provoke their reply. In this man's case the Faradaic current 
at first caused no contractions ; and you might have gone on 
applying this current daily for month after month and year 
after year, not only without curing the patient, but without 
even checking the progressive degeneration and atrophy of the 
muscles. The galvanic current of a pretty powerful battery 
was necessary to start the cure, and bring it to the point where 
the Faradaic could continue it. I have never yet seen a case 
in which the primary current would not produce contractions, 
but I suspect that, if this man had gone a year longer without 
its application, it would then have failed to elicit them, and 
the case would have been hopeless. 

Chorea. — In this little boy we have an example of a dis- 
ease which you will meet with far more frequently — chorea. 
He comes from the Out-door Department of the Hospital, 
where he has been under the care of Dr. Castle, who gives me 
the following history : 

" Michael Prunty, aged ten years, born in the city, of Irish 
parentage. Applied for treatment at the Out-door Bureau of 
Bellevue Hospital, on the 4:th of October, having had chorea 
since the 29th of June previous. His mother says that about 
the 19th of June he went four times during the warmest part 
of the day to bathe in the Harlem Biver, and that on his re- 



50 CLINICAL LECTURES. 

turn liome in the evenins^ liis face was swollen and the whole 
surface of his body congested. During the night he was de- 
lirious. The next night the fever and delirium were repeated. 
After this he appeared to be well, until the morning of the 
29th, when, on getting up from bed, he had loss of power, and 
choreic movements of left side, and then told his mother that 
since the fever of the week before he had felt weak on that 
side. 

" The choreic movements were at first limited to the left 
side, but had increased in, severity, and, about a fortnight. be- 
fore coming to the dispensary, the muscles of the right side 
had commenced to twitch, and were becoming progressively 
worse. Could, by an effort of the will, control the movements 
of the right, and for a few moments those of the left side. 
Movements not interrupted during sleep. JSTo impairment of 
sight, or strabismus. Hearing not affected, but for the first 
month following the attack heard noise of waves on left side. 
Was always easily angered, and since the attack is more wil- 
ful and peevish than before. The choreic movements of tongue 
prevent his talking much. Is awakened with difficulty when 
asleep. 

" Digestion feeble. Has always been a dainty feeder, and 
would never eat fat meat or much butter. Has never had 
rheumatism. JSTo hereditary tendency to disease of nervous 
system. Some of his ancestors have died of phthisis. 

'' Stethoscopic examination of chest is difficult on account 
of the twitching of the muscles, but no rigors were detected of 
disease, excepting irregular contractions of the heart. Urine 
passed in the morning neutral." 

The symptoms are not at present so well marked as I would 
be glad to have them for your sake, though for the boy's I can- 
not well object to his having gone on so far toward recovery. 
He can hold out his arm and keep it pretty still, but the fingers 
are spasmodically extended, and now and then there is a sud- 
den movement of flexion or rotation. 

Regarding the pathology of chorea, we are in great uncer- 
tainty. We cannot even say what is the organ affected ; some 
authors locate the disease in the brain, others in the spinal 



J 



CHOEEA. 51 

cord, others again in tlie general nervous system. My own 
opinion is tliat, itncler the name " chorea," there are confounded 
two or three distinct affections, just as locomotor ataxia was 
lately confounded with several other diseases of the cord, and as 
almost all shaking palsies were, until two or three years since, 
called indiscriminately "paralysis agitans." My friend Dr. 
Ogle, of London, lately wrote a monograph upon " fatal chorea," 
and reported some fifty autopsies of such cases. The diseased 
action had almost always been confined to one side of the 
body, and the lesion was found in the corpus striatum. This 
was certainly a very different affection from the chorea which 
you may see almost daily in our dispensaries, and which almost 
always gets well. I believe that the ordinary chorea of cliildren 
has its seat in the cord. At the same time it is very common 
to find it associated with mental symptoms more or less pro- 
nounced. The child is less bright than before, or it may even 
become imbecile; it shows aberration of disposition and will, 
and in place of its usual gayety it becomes peevish and fret- 
ful. This is what you would expect. In disease of the 
stomach or liver we often find the brain affected secondarily ; 
and it is very rare that there is any serious disease of the 
cord without its producing this result. In older patients the 
mental symptoms are sometimes remarkable. I have now 
under my care a choreic young man who is often put in 
the most embarrassing positions by the fact that he cannot 
control his speech. He finds himself irresistibly impelled to 
say things which he would fain avoid, and this unfortunate ten- 
dency debars him entirely from the society of ladies. When- 
ever he meets them, he is sure to utter something to his own ' 
deep mortification. This has been his condition for several 
months. I knew a similar case in a wealthy gentleman of 
Harrisburg, who would be making a social visit and conduct- 
ing himself with the utmost propriety, when suddenly he would 
jump up, stamp his feet, swear violently, and then, covered 
with confusion, make his escape from the house. 

As to the causes of chorea, the disease has been commonly, 
and until very recently, supposed to be intimately connected 
with rheumatism. If I mistake not, I gave you that as my 
own opinion last year ; but, as I have before warned you, I 



52 CLERICAL LECTUEES. 

often find occasion to change my views, and, if you come to 
these lectures, you must not expect always to hear the same 
thing. The theory of the rheumatic origin of chorea came 
into YOgue mainly through the influence of Trousseau. He 
thought he had found it most frequently associated with the 
rheumatic diathesis, especially where this had produced disease 
of the heart ; and his idea was, that the chorea was, in many 
instances, due to embolism of the arteries of the brain. Xow, 
further investigation has shown that this is not the case — that 
none of the symptoms of embolism are present in chorea ; 
and a very extensive study of hundreds of cases has convinced 
me that there exists no connection whatever between chorea 
and rheumatism. There are other causes, however, which 
noue deny. Any thing which tends to depress the powers of 
the system — improper food, bad air, want of cleanliness, etc. — 
may become a predisposing cause, and then almost any iiTegu- 
larity may determine the outbreak of the disease. Worms 
may excite it in young children. It may be brought on by 
fright, or other violent excitement, and this in persons who 
have appeared in perfect health and under good hygienic con. 
ditions. Some of the most interesting cases I have ever seen 
were caused by fright. Two or three have been due to over- 
study at school, which is, as you know, one of the means by 
which the powers of the system may be very materially de- 
pressed. 

The prognosis of the disease as it occui*s in children is almost 
invariably good. When I last looked at my table of cases, I 
had recorded accurate notes of sixtj-eight, and of these only 
two had become confirmed. All the rest either were cured or 
got well, and even the two persistent ones may recover as the 
age of puberty comes on. The duration of the disease is gen- 
erally about two months. That is just about the average of 
my cases. You can give your prognosis, therefore, with a good 
degree of definiteness, and so greatly encourage the child's 
parents or friends. 

The disease occurrins^ in adults is a totallv difi'erent thino;. 
In them you do not often find the choreic movements constant. 
I have in mind the wife of a prominent man of this city who 
lias been subject to the affection for a long time. She will for 



CHOEEA. 58 

days seem perfectly well. Then, suddenly, she will whirl 
about on one toe for an hour, until completely exhausted. 
Again, she will have a spell of getting up and sitting down in 
her chair, with such force as to bruise the nates. At other 
times she will jump steadily until her strength gives out. 

A few words reo-ardino; treatment. I have called attention 
to the fact that the children who are subjects of chorea nearly 
always get well. I do not think you can do much to render 
the recovery more certain, but you may most certainly do 
much to shorten its period. For the last two or three years 
my great reliance has been upon strychnia. I commonly be] 
gin by given one-sixtieth of a grain three times a day, 
and gradually increase the dose to one-twentieth. This has 
proved almost uniformly and quite speedily successful. Some 
of you will remember the boy brought here last year by my 
friend Dr. Lusk. He had been treated for months without 
benefit, but, when put upon strychnia, got well in two weeks. 
When I spoke of the average duration of the cases as being 
two months, I meant their duration not left to themselves, 
but put under judicious treatment. 

If you see a case when it first comes on, you may cure it 
in ten days by the application of ether-spray to the spinal col- 
umn. Strip the patient to the buttocks, and, with an atom- 
izer, throw the spray all the way up and down the spine for 
about 'Rye minutes. Do this three or four times a week, or, in 
extreme cases, every day. From six to ten applications will 
usually effect a cure. I have never seen a case resist longer 
than two weeks. The method is not my own, although I am 
not aware that any one else has used it here. I found it lately 
in a German journal, and have now tried it in some eight or 
ten cases. 



54 CLINICAL LECTURES. 

LECTUEE Y/ 

APHASIA. 

I YESTERDAY brought before jou tlie subjects of cerebral em- 
bolism and thrombosis, and one of the consequences of those 
affections, softening of the brain, or ramollissement To-day 1 
shall take up another very important consequence, aphasia, 
which the cases you see present will very clearly illustrate. 

By aphasia we mean loss of the power of speech ; but, of 
course, we restrict the term to express that loss only under cer- 
tain conditions. Thus, if a man is struck senseless by a blow, 
or if he has his tongue cut out, we do not call his inability to 
speak, aphasia. The word is used to signify the loss of the 
ability to express ideas by language, either from forgetfulness 
of the words to be employed, or from lack of power so to 
coordinate the muscles of speech as to articulate them when 
remembered. Of the distinction between these two kinds of 
aphasia I will speak further on. But first a few words with 
regard to the faculty of speech, and the location of its organ in 
the brain. That such a faculty exists there can be no question, 
but that it, or any other intellectual faculty, has any special 
part of the brain appropriated to it, has been a matter of grave 
arid often bitter dispute. Without entering into a discussion 
of the general question, which would show us overwhelming 
and, in my opinion, conclusive arguments in the affirmative, 
let us glance at its history with reference to this special faculty 
of language. 

In the early part of this century. Gall, the father of Phre- 
nology — a man far more scientific than the vagaries of many of 
his would-be followers have led most of us to believe ; a man 
who has done more to establish the study of the anatomy and 
physiology of the brain upon its proper basis than any one else 
that ever lived — ^located the organ of speech in the lower part 
of the anterior lobes of the brain, that part resting upon the 
supraorbital plate of either side. According to him, the full 
development of this organ would depress the supra-orbital 

^ Phonograpliic report of Dr. Jolm Winslow. 



APHASIA. OD 

])late, and piisli tlie eyeball forward. Prominence of the eyes, 
therefore, was, in his system, the sign characteristic of those 
persons endowed with great powers of language. 

Some years later, Bonilland adopted and supported Gall's 
view, locating the organ of speech in the anterior lobes. Sub- 
sequently to him, Marc Dax published a memoir — for a long- 
time overlooked — locating it exclusively in the left hemisphere 
of the brain ; and, a quarter of a century later, in 1863, his 
son, George Dax, presented a paper to the French Academy, 
in which he claimed a very limited region as the seat of the 
organ, namely, the outer and anterior part of the middle lobe 
of the left side, immediately bordering on the fissure of Syl- 
vius. Two years before this, Broca, who seems to have been 
ignorant of the observations of the elder Dax, had announced 
that the organ was situated in the posterior part of the third 
convolution of the anterior lobe of the left side. Subsequent 
investigations have pointed to the " island of Reil," at the 
other extremity of the fissure of Sylvius, in the left side, as 
its probable seat ; and a still later view, that of Hughlings 
Jackson, includes the last three by broadly stating that it is 
located in some part of that region of the left hemisphere, in 
the immediate vicinity of the fissure of Sylvius, which is 
nourished by the middle cerebral artery. 

How do we arrive at such a physiological fact as this, if 
fact it be ? There are four classes of indications by which we 
may hope to discover the function of an organ — 1. Those of 
anatomy ; 2. Those of comparative anatomy ; 3. Those of ex- 
periment ; and, 4. Those of injury or disease. 

1. The history of physiology has shown it to be very rare 
that the scalpel and the microscope alone enable us to deter- 
mine the function of a part. Even so simple a problem as 
the mechanical action of some of the muscles remained un- 
solved until the electric stimulus came to our aid ; and w^e 
certainly could not expect to differentiate the functions of dif- 
ferent parts of the brain by anatomical considerations only. 
But it has been strongly claimed that the continuity of the 
several parts of either hemisphere, their similarity of structure, 
and especially the symmetry of the two hemispheres, preclude 
us from locating any faculty in one part rather than another. 



56 CLI^^ICAL LECTURES. 

and particularly from confining it to one side of tlie brain. 
To this it iniglit be replied that sncli a priori assumptions 
have no place in inductive science. But let us look at the 
facts. When you examine the two anterior lobes of a human 
brain, your first impression is that they are just alike. Closer 
inspection, however, shows you that the convolutions are not 
strictly symmetrical in their arrangement upon the two sides ; 
and that the third convolution of the left side is larger than 
that of the right. Moreover, the gray cortical substance va- 
ries in thickness in different parts of the same side, and un- 
symmetrically on the two sides. Xow, take your microscope, 
and place under it thin sections from twenty or fifty difiPerent 
parts of the brain. You will find no two exactly alike. There 
is variation in the size of the cells, in their arrangement with 
reference to each other, and in their arrangement with refer- 
ence to the white fibres. But suppose that the microscope 
showed one part of the brain like every other, and that, even 
by this means, no difierence could be discerned between the 
two hemispheres, would that be any proof that the different 
parts, or the two sides, were alike in function ? Examine 
under the microscope a section of the lachrymal gland and a 
section of the pancreas, and if you can detect the slightest dif- 
ference between them you have better eyes than mine ; yet the 
difference in function in these two glands, the difference in 
the properties of their secretions, is not a matter of question. 
You can easily multiply such examples ; but this one is suffi- 
cient to show the fallacy of the style of argument Ave are con- 
siderino; ; to show that, with reo-ard to the PTeat o^land which 
secretes the mind (so to speak), we can predicate nothing of 
the functions of its special parts from their gross or then- mi- 
nute appearances. "We have seen, then, that the different 
parts, and the opposite sides, of the brain are not alike ; and, 
furthermore, that, if they were, it would be no argument to 
prove their identity of function ; and so we dismiss the objec- 
tions, based on considerations of anatomy, to the localization 
of the faculty of speech in the region I have indicated. 

2. The argument from comparative anatomy we will not 
stop to consider. Suffice it to say, that it throws much less 
light upon this question than upon some others in nervous 



APHASIA. 57 

pliYsiology, as, for example, tlie determination of the ganglia 
presiding over certain of tlie special senses. 

3. [N'eitlier does experiment help ns mnch here. Bonilland 
performed some experiments npon dogs, which, in his own 
opinion, corroborated his theory, the animals apparently losing 
the power to bark after injury to the anterior cerebral lobes. 
But we cannot accept such a result as satisfactory ; for we 
have no right to assume that the bark of a dog bears any 
analogy to our own articulate speech; we have certainly no 
evidence that they communicate ideas by this means. It is, of 
course, unjustifiable for us to experiment upon the human 
brain ; sometimes, however, accident does this for us, and 
several interesting cases have been recorded in which inju- 
ries to the very limited region I have named have been fol- 
lowed by loss or aberration of speech, while other cases in 
which this part escaped, though the destruction of other parts 
was far greater, left the speech unimpaired. 

4. The best of all experiments are those performed for us by 
nature in her pathological processes. For nature does the work 
more neatly than we can ever hope to do it. She can de- 
stroy a given part of the brain without the slightest injury to 
any other, and so gradually as to produce no shock, thus get- 
ting rid of the complications that are so apt to vitiate our ov/n 
results. There are various ways in which a limited part of the 
brain may be affected pathologically, for example, by cystic or 
other tumors, or by hgemorrhage of small extent. But, among 
the most interesting and instructive of them all, are the two we 
have lately been considering, thrombosis and embolism,^ which, 
by more or less completely cutting off the blood-supply of a 
given region, impair or abolish its functional power. You 
know that the middle cerebral artery, which is the direct con- 
tinuation as well as the largest branch of the internal carotid, 
is lodged in the fissure of Sylvius on either side of the brain. 
Kow, we find that when the left middle cerebral artery is 
plugged by a thrombus or an embolus, the faculty of speech is 
commonly impaired; when the right one is plugged, this 
faculty does not suffer. But it is not in every case of this 
kind that we have opportunity for an autopsy ; how, then, can 

' See pp. 1-14. 



58 CLmiCAL LECTUEES. 

we tell which side is affected ? This same artery, which sup 
plies the region designated as that of the organ of speech, 
supplies also the corpus striatum, the great motor ganglion. If 
the current of blood is stopped by a plug occupying its main 
trunk, the corpus striatum loses its power, and we have motor 
paralysis of the opposite side of the body. The situation of the 
attendant hemiplegia, then, tells us unequivocally upon which 
side of the brain is seated the lesion which causes the aphasia. 
Out of 608 cases of aphasia with hemiplegia which I have 
collected, I find only two where the paralysis was on the left 
side. The same preponderance of evidence is found in the 
situation of the various lesions revealed by autopsy. ISTearly 
all the facts go to show that injmy or disease of the posterior 
and lower part of the left anterior lobe, or perhaps more es- 
pecially of the island of Reil, is attended with aberration of 
speech, while lesions of other parts are not so attended. 

I have spoken with much positiveness upon this point, to 
impress upon you the strength of my own conviction. At the 
same time I am bound to tell you that there are some excep- 
tions — and a single one would be sufficient to overturn the 
theory that the organ of speech is located exclusively in that 
part of the left hemisphere which has been described. There 
are rare cases of left hemiplegia attended by aphasia. There 
are also some cases of aphasia in which post-mortem exami- 
nation has sho^vn lesion of the right side of the brain alone. 
How can we explain these seeming anomalies ? A simple and 
ingenious explanation has been proposed by Moxon, of Lon- 
don, which you can accept or not as you please. It is proba- 
ble that at birth the two sides of the brain are essentially alike 
in structure and functional capacity, and that both are prepared 
to take upon themselves the control of the faculty of speech. 
But the left — which has been shown by Gratiolet to be the 
earlier developed in the foetus, and the better supplied with 
blood — ^is somewhat the stronger, and gets the preference ; and 
this preference, once instituted, tends to maintain itself by 
force of habit, and the gain of strength from exercise. As the 
child grows, therefore, the differences in function and in struct- 
ure of the two sides become more marked. The case is pre- 
cisely analogous to that of the right and left hand, the right 



APHASIA. 59 

for a similar reason gaining the precedence, and then steadily 
widening tlie difference between itself and its fellow. These pe- 
culiarities are hereditarily transmitted, and probably at least 
nineteen children ont of every twenty, if entirely nntanght, 
wonld grow np right-handed and left-brained. But the twen- 
tieth child would be left-handed ; and he may very probably use 
the right hemisphere in preference, for the faculty of speech. 
Certain it is that in some of these eases of aphasia the patients 
have afterward learned to speak. That they have done so by 
developing the power in the right side of the brain is made 
eminently probable by the fact that the left has been found 
alter death disorganized and apparently unfit for any func- 
tion. 

The cases before you confirm the views I have expressed. 
They each exemplify one or more of the several forms of 
aphasia — amnesic aphasia, ataxic aphasia, and agraphia — 
terms whose explanation I have reserved until now. 

Amnesia means forge tfulness, and amnesic aphasia is that 
form in which the patient cannot express his ideas because he 
cannot recall the words which custom has appropriated to 
them. It is not that he forgets how to articulate a word 
whose sound he remembers ; for in some rare cases of purely 
amnesic aphasia any word spoken to the patient he can im- 
mediately repeat with distinctness, though he could not do 
so a minute afterward ; but it is the word itself, the combi- 
nation of sounds that stands as the symbol of an idea, which 
he cannot recall at will. 

Ataxia means incoordination, and ataxic aphasia is that 
form in which the patient, though recollecting the word he 
wishes to use, cannot articulate it. In the typical case this is 
not due to any paralysis of the muscles of articulation, for the 
lips, tongue, and palate, can be made to assume every position 
necessary for the formation of all the vocal elements. The pa- 
tient has simply lost the power to bring these muscles into the 
consentaneous action required for speech ; he cannot begin to 
speak the word, for he has forgotten how to will the neces- 
sary movements ; he is much in the condition of the infant 
that has never learned to utter words that it still can under- 
stand. In some cases this ataxia extends to all the muscles of 



60 CLINICAL LECTURES. 

articulatiou ; in others it is confined to a particular gronp, as 
those of the lips, for example. 

It is very seldom that we find a case in which either of 
these forms of aphasia is absolute, in which there is inability 
either to recall or to pronounce any word whatever. Yet the 
affection is often very profound, so that the patient may be 
able to say only one or two words from memory, or to repeat 
only one or two when prompted. The curious phenomena 
that are sometimes developed from a combination of the two 
forms in various degrees of intensity, offer a most attractive 
subject for physiological and psychological speculation; but 
we must not be tempted to pursue this here, and the phenom- 
ena themselves will be better apprehended from a study of 
cases than from any remarks of mine. 

Agraphia means inability to write. This, like aphasia, 
may be of two kinds. The patient may be unable to write a 
word because he cannot recall the word, or cannot recollect its 
written form ; or he may be unable to write it because he 
cannot coordinate the necessary movements of the hand. In 
the latter case he cannot write from copy ; in the former he 
can probably copy with more or less facility. 

Language, in its most general sense, includes every means 
of communicating ideas. We may do this by writing or by 
gesture, as well as by articulate speech. In those languages 
where the written characters stand for things and not for 
words, the written and the spoken language being thus inde- 
pendent of each other, it is quite conceivable that there may 
be an amnesia of the written signs of ideas and not of the 
spoken, and vice versa. Even where the written language is 
phonetic, like our own, the same thing may perhaps be pos- 
sible, though purely amnesic aphasia, without agraphia, would 
indicate that the written words had become to the mind the 
direct symbols of ideas (as they must be to congenitally deaf- 
mutes). That we may liave ataxia of speech and of writing 
quite index^endently is well established by numerouis cases. 
What we have said of speech and of writing w4]l apply also to 
gesture, or pantomime, so far as this is arbitrary and not in- 
stinctive. 

To enable us to speak, there must be several organs in a 



APHASIA. 61 

state of integrity — tlie ear to collect sound, the auditory nerve 
to convey it to the brain, a ganglion to convert it into sensation, 
an organ to convert the sensation into an idea, and an organ 
to convert that into a motor impulse, sent to the muscles of 
speech. It is clear that the ear must do its work, that we 
cannot speak unless we have first learned what words are. 
Deaf-mutes, born deaf, are mute simply because they have 
never been able to form a conception of what sound is. They 
have no paralysis or incoordination of the muscles of articula- 
tion, and they cannot have forgotten what they never learned ; 
they are not, therefore, properly aphasic. In cases of aphasia 
the difficulty lies in the ganglia which should convert the sen- 
sation into an idea, and send down the motor impulse to the 
organs of speech. 

Let us now look at some cases. Two of the patients before 
you you have previously seen. 

William Wice ^ you will recollect as a case of thrombosis, 
probably of the left middle cerebral artery, resulting in right 
hemiplegia and ataxic aphasia, the difficulty of speech being 
greatest with labials and least with gutturals. Under the 
treatment by phosphorus and electricity he has greatly im- 
proved, so that he can now say " Peter Piper " without hesi- 
tating or stammering. He used to say, " P-p-p-p-p-p-peter." 

The next man, Eichard Murphy,'^ you remember, had five 
attacks of cerebral embolism, causing hemiplegia, sometimes 
very transient, sometimes more persistent, always on the right 
side, and attended by amnesic aphasia. He is considerably 
better than when we last saw him, and when I ask him to 
say, '' tea, cofiee, sugar, crackers," he begins boldly, and goes 
bravely on through the tea, coffee, and sugar, but breaks down 
before the crackers. 

'Now 1 have to present to you a case similar in some 
respects to the last, and of remarkable interest as confirmatory 
of the theory that the organ of speech is located on the left 
side of the brain. This man is a patient in Bellevue Hos- 
pital, and the following notes of his case have been taken 
down by Dr. Schuyler, assistant house-physician : 

^ Psychological Jouenal, vol. v., p. 2. ^ Ibid., vol. v., p. 10. 



62 CLINICAL LECTUEES. 

Repeated Hemiplegia from Emholism — the Rigid Hemi- 
plegia attended hy Aphasia, the Left not so attended. — "Den- 
nis C. Minton, Irisli, aged forty-four, married, clerk, admitted 
to Ward 14, Bellevue Hospital, N"ovember 19, 1870. Gi^es a 
syphilitic history. Has been a hard drinker for twenty-five 
years. Three years ago last March, while walking in the 
street, he felt a sensation like that of the prod of a pin in the 
left elbow, and his arm dropped powerless. Twitchings of the 
muscles of the arm and side of the face then began ; and head- 
ache and dizziness, with cloudiness before the eyes, came on. 
The twitching of the muscles lasted about seven minutes, 
when he recovered the use of his arm, though it still felt very 
weak. The dizziness and headache remained. This attack 
was repeated two days afterward, and again a w^eek after 
that. He then went to the City Hospital, where he had three 
more attacks. He remained there about four wrecks. After 
leaving he began to drink hard, and the spasm returned again. 
He now entered the Long Island Hospital, where he recovered, 
under the use of electricity and a seton in the back of the 
neck, and had no more spasms until last summer. Before this 
trouble began, he had had an attack of gout in his left toe, 
and this has troubled him at intervals since. With the ex- 
ception of these attacks of gout, he continued well until last 
summer, when, in the hot weather, after he had been drinking 
hard, he felt as if a pin had been thrust into his head, and 
dropped insensible. He was unconscious for about a minute, 
and when he awoke complained of headache, dizziness, and 
a feeling as if sponges were under his feet while he was walk- 
ing. He was brought to the hospital ; and about two weeks 
afterward he suddenly became dizzy, lost his speech, and lost 
the use of the tips of the fingers of his right hand. This 
shock lasted about two minutes. Some two weeks later, he 
had another shock of the same description, and lost the use of 
his hand up to the wrist. These attacks were repeated every 
one or two weeks, [the paralysis] gradually extending up until 
the right side of the face was afiected also. The attacks lasted 
from one to six minutes. There was never any twitching of 
the muscles of the right arm, but there is of those of the side 
of the face. When it reached the side of the face, he had a 



i 



APHASIA. 63 

roaring noise in tlie side of the liead during the attack. After 
each attack he felt weak and dizzv. The last attack occurred 
the day before admission, and, besides following the usual 
course, extended like a shock down his right side. His speech 
and sight have been imperfect since this last attack. Nine 
months ago he had an attack of Bright's disease. His feet 
have frequently been swollen since. His sight has been more 
or less imperfect ever since this attack ; and, since the shock on 
the day before admission, he has been unable to read at all. 
He is subject to attacks of rheumatism. On admission, bowels 
costive ; tongue furred ; feet somewliat swollen ; water normal 
in amount and containing no albumen ; physical examination 
of heart and lungs negative ; appetite good." 

The symptoms in this case are so exactly those of embolism 
that I cannot attribute them to any other cause. We have a 
history of rheumatism ; and, although at first the auscultation 
gave but a negative result, yet Dr. Flint now discovers a mur- 
mur at the base of the heart, and so do I. This murmur is not 
such as to indicate positively organic disease ; it does not show 
either roughening or insufficiency of the valves, such as would 
be likely to result from fibrinous concretions upon them. But 
it is not improbable that the patient may have had endocardi- 
tis, and that such concretions may be scattered about the walls 
of the heart, among its fleshy columns. Here they would give 
no certain evidence of their presence, and we should first be 
led to suspect it by their becoming detached and being sent 
into the circulation as emboli, to plug up some distant artery. 
This man has had eleven attacks of vertigo, unconsciousness, 
and hemiplegia. Whenever the attack has paralyzed him 
upon the left side, he has had no difficulty of speech ; but, 
whenever he has been paralyzed upon the right side, he has 
lost the faculty of speech for the time. Of course, in the for- 
mer cases the emboli were lodged on the right side of the brain, 
in the latter on the left, and most probably in the middle cere- 
bral artery, since that is the artery most apt to be plugged, and 
also the one whose plugging is most apt to cause aphasia. 

I have had the good fortune to meet with another case very 
similar to this. A former officer of the army, a private pa- 
tient of mine, had eight attacks of embolism, following a liis- 



64 CLINICAL LECTUEES. 

tory of acute rlieumatism and valvular derangement of tlie 
lieartj detected several years before. When he came under my 
charge he was suffering from one of these attacks of embolism, 
attended by paralysis, difficulty of speech, and other symptoms. 
He had seven attacks subsequent to that one, some paralyzing 
him on the right, some on the left side ; and, as in the case 
before us, with the left hemiplegia he had never any difficulty 
of speech, with the right he always had. 

ISTow, I say that two such cases as these are almost abso- 
lutely conclusive that the faculty of speech is more intimately 
connected with the left hemisphere than with the right — mind 
that I say more intimately connected with the left hemisphere, 
for I do not pretend to believe that it is exclusively connected 
with it. 

I have now another case of much interest to bring before 
you. This lady is a private patient of mine, and she has con- 
sented, at great personal inconvenience, to come here to-day 
and allow me to present her case to you. The following very 
(complete history has been prepared by Dr. Cross : 

Amnesic and Ataxic Ajphasia^ with Agraphia and Right 
Memijplegia. — Mrs. W., thirty-two years of age, born in IS'ew- 
York City, married, and the mother of ^nq children, of whom, 
at the 23resent time^ four are living. The youngest child is 
eleven months old, while the eldest is eleven years. She is a 
lady of a pale complexion, rather delicate, of a nervous tem- 
perament, and of medium height, and endowed originally with 
much intelligence, culture, and refinement. 

There is no venereal taint in her family. She has never 
had acute articular rheumatism, nor in fact any severe illness 
prior to the year 1860 ; but, on the contrary, has enjoyed tol- 
erably good health, such as we might hardly expect from a 
lady of her delicate organization, if we except a severe attack 
of intermittent fever, which she had when sixteen years old. 
Her father, when about forty years of age, was paralyzed on 
the left side of his body, and at the same time his speech was 
much affected. He recovered the faculty of speech in time, 
but was not so fortunate in regard to his paralysis. After the 
lapse of twenty years, he had a second attack, which again in- 
volved the faculty of speech and the left side of his body. In 



APHASIA. 66 

the due course of time he completely regained the normal use 
of the faculty of speech, but his hemiplegia persisted until his 
death, which occurred some years later. Her grandfather, on 
her father's side, who was one of the assistant ministers of 
Trinity Church, was suddenly seized in the pulpit, in the midst 
of his discourse, with the apoplectic form, par excellence^ of 
cerebral haemorrhage, and almost immediately expired. With 
these exceptions there is no hereditary predisposition to other 
diseases of the nervous system in the family. 

During the month of February, 1860, about three wrecks 
after the birth of her second child, having complained for sev- 
eral days of a severe pain in her right shoulder, which ex- 
tended down the right arm, symptoms of albuminuria, accom - 
panied with general dropsy, supervened. These were so rap- 
idly developed, that at the end of two weeks the dyspnoea had 
become so great as seriously to compromise the life of the 
patient. The anasarca, which was the cause of the impeded 
respiratory movements, had induced not only ascites but also 
liydrothorax and oedema of the lungs. Gradually the patient 
became more or less stupid, and at this stage a slight urgemic 
convulsion followed. Her urine was now examined, and 
found to be loaded wdth albumen. Shortly after this attack 
of eclampsia, as she was sitting, leaning forward, with her 
head resting upon a pillow at the side of the bed, tlie most 
comfortable position which she could assume in her terrible 
distress, she was gently aroused from her semi-conscious con- 
dition, when it was found that she was completely hemi- 
plegic on the right side of her body, and that she was 
totally unable to utter a single audible sound. For at least a 
week after this discovery she was greatly confused in regard 
to her ideas, and it w^as fully six weeks before the dropsy had 
quite disappeared, during which time she was confined to her 
bed. The period of the convulsion marks the acme or crisis 
of the albuminuria, as the patient from that period began to 
recover from the very alarming dyspnoea which had almost 
suffocated her. 

On examination, soon after, motility, tactile sensibility, 
and the sensation of pain, were discovered to be nearly abol- 
ished on the whole right side of the body. The face was 



66 CLIISICAL LECTURES. 

drawn to the left side, and there was a marked deviation of 
the tongne in the same direction. There were strabismus and 
partial ptosis of the left eye, with a widely-dilated pupil, which 
did not respond readily to light. The angle of the month 
was depressed on the diseased side, while the opposite angle 
was on a higher level than its fellow wonld be in a normal 
condition. 'No'W she could ntter unintelligible sounds, which 
could not, however, be interpreted into intelligible words. 
For about three years and a half a very gradual and progres- 
sive improvement took place in her right upper and lower 
extremities, but even at the end of this period there was still 
a considerable amount of paresis in these parts. The face was 
still drawn to the left side, and the integrity of the muscles of 
the eye had not, even after this lapse of time, fully recovered 
their accustomed contractility. The tongue did not deviate. 
The sensibility to touch and to pain was still impaired. She 
could not sew, not so much from a lack of power to hold her 
needle as a want of sensibility to guide her in directing its 
movements ; yet, by supplying by means of sight the absence 
of this special sensibility, she was able to accomplish many 
things with her right hand which she otherwise would have 
been totally unable to perform. Her special senses, excepting 
tactile sensibility, were normal, and her general health had 
much improved. At this period her urine was again examined, 
and no albumen or casts of any kind were discovered therein. 
Until the summer of 1863 she had not, for three years and a 
half, enunciated an intelligible word, and it was about this 
period that she one day suddenly exclaimed " No ! " the first 
word clearly spoken in all this time. A month later she was 
able to say " Yes ! " With these few words, assisted by her 
excellent gestures, she managed to make her wants known 
and to communicate her ideas to her friends to some extent. 
Shortly after the births of her last two children there again 
followed general anarsarca, but not to the same extreme de- 
gree as in the preceding attack, there being no shortness of 
breath or other dangerous symptoms. This condition soon dis- 
appeared, however, on the administration of powerful diuretics. 
Such is the history of this most interesting case up to the 



APHASIA. 67 

time when she came under onr observation in October, 18Y0, 
at which period she was in the following condition : 

She appears to enjoy good health, with the exception of 
frequent headaches, which have only made their appearance 
lately. These are severe in character. Her face is pale, 
but this has always been so ever since childhood. She has, 
however, a remarkably bright^ intelligent, and animated ap- 
pearance, and when spoken to she seems to fully understand 
every thing that is said. She is fully conversant with the 
use of all objects with which she was once familiar, althougji 
she cannot call them by name, partially from the fact that 
she does not remember the symbols or words which ex- 
press the ideas. She attends to all her household duties and 
knows perfectly well how to supply all the wants of her 
numerous family. Although seemingly quite intelligent, 
she at times becomes very much confused in her ideas, as 
evinced by her imperfect gestures and obtuseness of compre- 
hension. She is only able at the present time to articulate 
the words '' Dado," " Yes," " E'o," " Yes, no," and " 'No, yes," 
which she uses in reply to all questions. " Dado " is a word 
by which she means to express " yes," and at times she makes 
use of it almost exclusively. If asked what is the name of an 
object — as a fan, for instance — she is totally unable to tell the 
sign or symbol which expresses the idea in language, yet she 
indicates clearly enough its use by the gesture of fanning her- 
self. She is able to communicate some of her thoughts to her 
family or her friends quite fluently by the means of an expres- 
sive pantomime, and her gestures are so perfect that most any 
person, after a little practice, could understand very well most 
of the many ideas which she might wish to impart. She is 
quite unable to read, as was soon discovered by testing her 
capacity in this respect, in different ways, and at various 
times. Webster's large dictionary was given to her, and she 
was requested to point out the letters contained in the word 
" yes ; " yet even this she could not do until the y was first 
pronounced and pointed out to her, and then, after clearly 
enunciating the letters e and s, she with difficulty found them. 
The JS^ew York Daily Times was next handed to her, and she 
was asked to place her pencil on each of the words which com- 



68 CLmiCAL LECTUEES. 

pose tlie heading, as tliej were slowly pronounced each sepa- 
rately for her ; although she was now and then correct, she 
was not sure, and was yerv often wrons^. She was next tried 
by means of the alphabet with large distinct letters, and the 
result was very far from satisfactory. She cannot enunciate a 
single letter of the alphabet distinctly, not even the letters 
contained in Dado, Yes, and JS^o, even if they be pronounced 
first for her, if they be separated apart from the word ; yet she 
can say, Yes no, JVo yes, and Dado. She is very apt at figures, 
and does all her own shopping, going to Stewart's, selecting 
whatever she desires, and, on arriving at home, every thing is 
found to be correct. She knows exactly how much she ought 
to pay for the article purchased, and how much is due her in 
return. All her communication of ideas is expressed by 
means of gesticulation. Her mind is very clear at times, and, 
while this history was being taken, she reminded her husband 
of several mistakes which he had made in regard to time and 
locality, and he certified, on refiection, that she was right. 
She can write the monosyllable ^^o, but that is the only 
word which she can write completely, although she was able 
to write Jar for " Jane," goo for " good," the words being first 
slowly spelled for her several times just before she tried to 
transfer them to paper. Certain objects impress her mind 
much more than others ; as, for example, she remembers the 
subject of a picture much better than the color, drawings 
much better than pictures. She now recalls many subjects of 
art in her husband's gallery, which formerly she could not do. 
Her right hand, as measured by the dynamometer, is a little 
weaker than the left, and tliis is evidently due to muscular 
paresis, as the patient is right-handed. The extensors of the 
i-ight foot lack their natm-al tonicity, so that the toe catches at 
times ; but, on the whole, without very close observation, this 
defect would not be noticed. The sensibility to touch and the 
sensation of pain are slightly impaired on the diseased side. 
There is a very weak mitral systolic murmur heard at the apex 
of the heart. The hmgs are normal, and so are the bladder 
and rectum. The urine has been microscopically and chemi- 
cally examined, with a negative result. The special senses, 
excepting tactile sensibihty, are unimpaired. There is no 



APHASIA. 09 

ptosis, no strabismus, and no defects in vision whatever. The 
pupils are equal, and respond readily to light. Ophthalmosco- 
pic examination of the eyes reveals a slightly-congested con- 
dition of these organs. There is no deviation of the tongue. 
There is no paralysis or paresis of the muscles of the tongue, 
which are perfectly mobile, nor are the lips weakened at all 
in theii' movements. The mouth is perfectly natural, and is 
not drawn to either side. There is no emotionable excitabil- 
ity displayed by the patient, as is so often fonnd in those snf- 
fering from cerebral haemorrhage. There are, however, two 
well-marked conditions in this case, which are found in man}^ 
aphasic patients, namely, the repetition of the same w^ord and 
the characteristic expression of great impatiance after an un- 
successful attempt to speak a word. There is no painful tight- 
ness in the throat. Her appetite is good, and all her excre- 
tory functions are normally performed. 

'' This was the patient's condition at the time she com- 
menced treatment. This has consisted in the internal admin- 
istration of phosphorus as follows : 9 • ^^^i phosphorati § ss, 
acacise mucilaginis §j, olei bergamii gtts. xl. S. Fifteen 
drops to be taken in a wineglass of water three times a day 
after meals; together with the application of the primary 
galvanic current to the head, the positive pole placed on one 
mastoid process, and the negative placed on the other, for the 
period of about two minutes, at times reversing the current 
pro re nata ; or by applying one of the poles to the fore- 
head, and the other to the nape of the neck. In this lat- 
ter way she felt the same current much more forcibly than 
when the poles were applied to the mastoid processes. She 
has received these applications first passing the current in one 
direction for a short time, and then in the other, quite regu- 
larly three times a week up to the present date, and she has 
taken her medicine regularly also, only intermitting it for a 
short tiuie at intervals, as necessity required. During the 
month of ^November, 1870, she suddenly one day exclaimed, 
' I don't know,' but she could not be made to repeat it, 
although begged to do so by her friends. One morning about 
this time she said very distinctly indeed, ^ How do you do ? ' 
' What are you doing here % ' but she seemed to be perfectly 



70 CLINICAL LECTUEES. 

imconscioiTS that she liad given utterance to any such expres- 
sions. Shortly after this, one Sunday she called to her hus- 
band, 'Papa, dinner is ready,' and then smiled. She is un- 
able to write these phrases, even if they are first pronounced 
and then slowly spelled for her ; and, at this period and even 
later, she had not repeated them. In regard to numerals, al- 
though she can count perfectly by means of her fingers, and 
make change readily, yet she cannot recognize the printed 
number when shown to her, much less can she represent its 
symbol upon paper, and much less still can she enunciate it. 
Although she can say no, after many trials, it was impossible 
to make her articulate one or even on, which is merely a 
transposition of the letters contained in no. 

" January 31, 1871, on examination, the patient, who had 
now been under treatment for about three months, was in the 
following condition : 

" She has gradually added to the small stock of words at 
her command, at one time a single word, at another a com- 
plete phrase, and many of the words thus acquired she is able 
to repeat at times, but she is unable to call them up spon- 
taneously as occasion requires, unless the sentence or word 
is first repeated to her, excepting a very limited number of 
them. The phrases which she does speak are not very dis- 
tinct, and there is a tendency on her part to abbreviate or clip 
the words. The following are sentences which she uses very 
frequently : ' How do you do, dear ? ' ' Dinner is ready.' ' I 
will see about it.' ' Yes,' with an occasional 'yes no, no yes.' 
' I will see.' ' Mary, here.' ' Walter,' ' baby,' ' chm'ch,' ' thank 
vou ' etc. Within a few davs she has said ' John — black- 



thread.' And to a friend who was going to the dentist she 
said, ' Are you going to the (with a motion of her hand to her 
teeth) ? ' Last evening she said perfectly distinctly ' A house.' 
Although she had just said a house, she could not repeat the 
word when requested to do so, yet it was enunciated for her 
very clearly. Day by day she is recalling words and frag- 
ments of sentences, like a child just commencing to talk ; with 
this difference, that a child can enunciate a letter better than 
a word, being a simple element, whereas this patient cannot 
articulate the name of a single letter, nor of a single number. 



APHASIA. 7 1 

yet she is able to utter occasionally, and at times more fre- 
quently, a whole sentence or a part of a sentence. She is able 
to point out very correctly all the letters of the alphabet, ex- 
cepting G and^, which she confounded with each other. Slie 
can comprehend the general idea of a paragraph, sucli as is 
contained in a letter or a primary reader, if it be sufficiently 
simple and abound with nouns, the meaning of wliich she 
seems to recall with much greater facility than the otlier parts 
of speech. She was given a letter which she had never seen 
before, and slie expressed to her husband, so that he under- 
stood her perfectly, the meaning of its contents, which related 
to matters of interest concerning a particular friend. She was 
again tried, and there was no doubt whatever that she quite 
readily recognized certain simple numbers and nouns, but in 
regard to the interpretation of other parts of speech there 
were grave doubts. A word, as river ^ was shown her, and she 
was asked its meaning, whereat she arose, walked to a picture, 
and put her finger on its representation in the painting. 
This is only one instance of the many words which she has so 
correctly interpreted. She can write at present no^ do, Walter, 
Jane, good, and Sarah, without any assistance whatever such 
as spelling the words, pronouncing them slowly or repeatedly 
for her, and this is done without a copy. Her name was writ- 
ten, and she copied it very well. She also wrote the numer- 
als 10, 20, and 50, quite legibly. More complex numbers 
than these she cannot even interpret, much less write them 
without a copy. In regard to copying, she displays much 
facility. She has improv^ed much in her general health, and 
latterly her severe headaches have almost entirely disappeared. 
There is still a slight loss of tactile sensibility in the tips of 
the fingers of the right hand. Her toe at the present time 
very rarely catches, except after excessive exercise. Her intel- 
lect is undoubtedly much impaired, and, although she is a]3- 
parently bright and intelligent, this is not actually the case. 
That the symbols or sign of ideas, when suggested to her, 
arouse the appropriate stimulus for a brief interval, there is no 
doubt, although not to the same degree as they would do in 
health ; yet, without this principle of suggestions, her ideas must 
be very limited, and must partake more of the character of 



72 CLINICAL LECTUEES. 

those impressions which we derive through the means of the 
senses, being ahnost in her case devoid of ideation. Although 
she can write certain words which she is totally unable to 
speak, on the one hand, yet, on the other, she can speak very 
many words which she is totally unable to write. 'Not only 
is there a loss of the memory of words, and a loss of' the har- 
monious action of the muscles used in the act of speaking, but 
there is evidently also an inability to appreciate the percep- 
tions of certain acoustic as well as certain optic impressions on 
the part of the supreme centres, and consequently there is an 
impairment of the faculty of expressing these ideas in writing. 

" T. M. B. C." 

This case illustrates, very happily, some of the most char- 
acteristic phenomena of aphasia. You see the lady's look of 
intelligence and animation ; and as I talk with her you observe 
that she seems to understand me perfectly, though she can 
reply to my questions only by certain expressions of affirmation, 
of negation, or of doubt. If I ask her my name, or her own, 
she cannot tell me ; but, if I give a wrong name, she in- 
stantly answers '']^o no," and, when I come to the right one, 
she appears pleased, and promptly says '* Yes yes." These 
expressions she employs correctly, and they mean no and 
yes respectively. " Yes no " or " no yes," in her vocabu- 
lary, expresses uncertainty, as you perceive when I ask her of 
matters about which she is in doubt. Her only other word, 
dado, she does not favor us with to-day. By no amount of 
effort can I get her to repeat any other word than these, how- 
ever simple, and however clearly it is pronounced for her ; and 
this is not from any defect of hearing or of intelligence, for it is 
evident that she understands the word and its meaning com- 
pletely. Her aphasia, then, is ataxic as well as amnesic. 
Here I show you some of her attempts to write. Ja?ie she 
spells by abbreviating it J?i / no she writes correctly ; but in 
good she cannot get beyond the first three letters. She has 
agraphia, therefore, which appears to be chiefly, if not wholly, 
of the amnesic form. 

What do you suppose is the cause of the asphasic condition 
of this patient ? Recollect that it came on very suddenly and 



i 



APHASIA. 73 

was complete from the first, and I tliink yoii will agree with 
me that nothing else explains it so well as embolism. Em- 
l)oli, Yon know, are not necessarily formed in the heart ; they 
may originate in other organs, and then become detached ; 
and we know that disease of the kidney, attended by albnmi- 
nuria,i3 very apt to lead to embolism. And this lady, yon will 
remember, was suffering from very severe albuminuria at the 
time of and before the attack. 

Embolism, as I have told you, is but one of many causes 
of aphasia. Another is cerebral haemorrhage. A gentleman, 
whom I saw in this city last summer, had an attack of apo- 
plexy while he was bending forward in bed. He did not lose 
consciousness for more than a moment, and perhaps not at all ; 
but he was paralyzed upon the right side, and he lost completely 
the power of speech. He made signs for pencil and paper, 
but when they were brought he made only meaningless scrib- 
blings, and could not form a single letter. Yet there was no 
paralysis of the left side, and he had before been able to write 
with the left hand, as he can now do. He was very anxious 
to express himself, and we brought him an alphabet ; but he 
could not point out the letters. He had lost, as completely as 
did this lady, all memory of words and their elements. 

Xow, both of these cases would, a few years ago, have been 
put down under the head of " apoplexy ; " for the term was 
loosely used to cover almost every condition w^hich came on 
with sudden unconsciousness. It is but lately that we have 
come to understand this subject of embolism, and you will 
look in vain for any mention of it in many of your standard 
text-books. So, if a man fell down in the street with stupor 
and paralysis from haemorrhage into the brain, he was said to 
have apoplexy. If he had the same, or similar symptoms, and 
the post-mortem examination discovered no clot, the attack 
was still called apoplectic, and was supposed to have been due 
to congestion which had disappeared — " congestive apoplexy." 
They even began to conjecture about " nervous apoplexy." 
If they had looked in the middle cerebral artery, they would 
in all probability have found a more satisfactory solution of 
the mystery. The word apoplexy, then, except in recent writ- 
ings, must be taken to mean simply a set of symptoms attribu- 



7-4 CLn^ICAL LECTUEES. 

table to a variety of causes ; just as I told you, some time siDce, 
tliat paraplegia was only a symptom, which might arise from 
the most opposite conditions. 

Before we understood this, and before we knew any thing 
about aphasia, many cases of this affection, depending upon 
so-called apoplexy, were recorded, which it becomes interesting 
to examine under the light of our present knowledge. A few, 
which I shall now refer to, will incidentally illustrate some of 
the curious phases that aphasia occasionally exhibits. In Forbes 
Winslow's " Obscure Diseases of the Brain" — a book as inter- 
esting as a novel, but better for summer recreation than for 
scientific study— he says : 

" Loss of speech has been known to occur without any pre- 
vious symptom of brain or nervous disorder ; in other words, 
there has been no headache, vertigo, noise in the ears, loss of 
sensibility, depression of spirits, affection of vision, or any 
other symptom to excite suspicion as to the presence of any 
abnormal state of the structure of the brain or condition of 
cerebral cu'culation." 

That is clearly embolism, which, you remember, gives no 
premonitory symptoms. He continues : 

" Dr. Graves cites the followino^ interestino- illustrative case : 
' A barrister was walking up and down the hall of the Four 
Courts, waiting for a case to come on, and chatting with one 
friend and another. As the hall was rather crowded and hot, 
he went out into the area of the courts for the sake of the air, 
and had not remained there more than ten minutes when an 
old friend from the country came up and spoke to him. He 
was pleased to see his friend, and wished to inquire about his 
family, when he found to his great surprise that he could not 
utter a single audible sound ; he had completely lost his 
voice. ' " 

Now, I venture to say that no possible condition except 
embolism could have given rise to that. The report goes on : 
" He recovered the use of his tongue in about three weeks.'^ 
That is, collateral circulation was becoming established. " But 
not completely, for some slowness of speech remained. . . . 
During the day he had several attacks of vertigo, and after- 
ward hemiplegia. For several hours, however, before distor- 



APHASIA. 75 

tion of tlie face or an j of tlie usual sjmptoms of paralysis had 
commeuced, the onlj existing symptom was loss of speech. 
This gentleman died of apoplexy in about two months." 

Observe how loose is this last statement. That " apoplexy " 
may have been due to another embolus, to thrombus, or to 
hiemorrhaore ; which we do not know. 

"A lady, after an attack of paralysis, lost all power of 
speaking, but was able to communicate, in writing, her wishes. 
When, however, doing so, she invariably wrote no when she 
meant yes, and vice versa. When she wrote ' I wish you to do 
so,' it was construed conversely. This patient, I am informed, 
is still living, the singular defect alluded to remaining unal- 
tered." 

I had, last summer, a patient under my care who was simi- 
larly affected. He invariably said just the reverse of what he 
intended. Ask him, "Do you like soup?" and if he did like 
it he would answer " N^o." Thus we see that, instead of abo- 
lition of the faculty of speech, we may have a simple aberra- 
tion of it, a partial aphasia. 

Here is another curious case from the same book, reported 
by Dr. Osborn : A gentleman, twenty-six years of age, profi- 
cient in French, Italian, and German, was attacked with apo- 
plexy ; became sensible in about a fortnight, but found himself 
deprived of speech. There was no paralysis whatever of the 
organs of voice or articulation, and he uttered a variety of syl- 
lables with the greatest apparent ease ; but what he said was 
a jargon quite unintelligible. The case was carefully studied 
by Dr. Osborn, and the following are among the points noted : 

" 1. He perfectly comprehended every word said to him. 
This was proved in a variety of ways unnecessary to describe. 

" 2. He perfectly comprehended written language. He 
continued to read a newspaper every day, and, when examined, 
proved that he had a very clear recollection of all that he read. 
Having procured a copy of 'Andral's Pathology ' in French, 
he read it with great diligence, having lately intended to em- 
brace the medical profession. 

" 3. He expressed his ideas in writing with considerable 
fluency ; and when he failed it appeared to arise merely from 
confusion, and not from inability, the words being orthograph- 



76 CLII^ICAL LECTURES. 

icallj correct, but sometimes not in their proper places. Latin 
sentences lie translated accurately. He also wrote correct an- 
swers to historical questions. 

"4. His knowledge of arithmetic was unimpaired. He 
added and subtracted numbers of different denominations with 
imcommon readiness. He also played well at the game of 
draughts, which involves calculations relating to numbers and 
position. 

"' 5. His recollection of musical sounds could not be ascer- 
tained, not knowing the extent of his knowledge of music be- 
fore the apoplectic seizure ; but he remembered the tune of 
' God save the King,' and, when ' Eule, Britannia ' was played, 
he pointing to the shipping in the river. 

6. His power of repeating words after another person was 
almost confiDed to certain monosyllables ; and, in repeating the 
letters of the alphabet, he could never pronounce ^, ^, u, v, w, 
X, 3, although he often uttered those sounds in attempting to pro- 
nounce the other letters. The letter i, also, he was very sel- 
dom able to pronounce. 

" 7. In order to ascertain and place on record the peculiar 
affection of language which he exhibited. Dr. Osborn selected 
and laid before the patient the following sentence from the by- 
laws of the college of physicians, namely : ' It shall he in the 
power of the College to examine or not examine any Licentiate 
previous to his admission to a Fellowship^ as they shall thinh 
fit.'' Having set him to read, he read as follows : An the he 
what in the temother of the trothotodoo to majorum or that 
emidrate ein einhrastrai mestreit to Jcetra totomhreidei to ra 
fromtreido as that 'ke'kritestP The same passage was presented 
to him in a few days afterward, and he then read it as follows : 
^ Be mather he in the hondreit of the compestret to samstreis 
amtreit emtreido and temtreido mestreiterso to his eftreido 
tumhried rederiso of deid daf drit des trest.'' Dr. Osborn ob- 
serves that there are several syllables in the above of frequent 
occurrence in the German language, which probably had made 
a strong impression on the patient's memory. But the most 
remarkable fact connected with the case was that, although 
he appeared generally to know when he spoke wrongly, yet he 
was unable to speak correctly notwithstanding, as is proved by 
the preceding specimen." 



APHASIA. 77 

Eeturniiig now to Mrs. W., what prospect can we liold out to 
her ? You will say that, when an aifection like this has lasted 
for ten years, and shown so little sign of yielding, we are not 
waiTanted in raising what mnst be delusive hopes by any words 
of encouragement. But I do not so regard the case. I shall 
not be snrprised if, nnder treatment, she really recovers the fac- 
ulty of speech to a very considerable extent. The attempts she 
has been of late so vigorously making seem to show some gain. 
Moreover, she appears to be passing through a sort of crisis, as 
indicated by the headaches she suffers from so terribly, espe- 
cially at night. 

How can we hasten the improvement which nature seems 
already to have begun ? What mnst be our treatment ? A 
great part of it must consist in diligent, persistent exercise. 
We must be patient, not expecting brilliant results at once, 
but content if we can secure a steady gaiu, however slow at 
first. You know to what an astonishing degree the memory 
can be cultivated ; how firmly things become impressed upon 
it by dint of frequent repetition. It is said that there is a com- 
positor in London who has set up the Bible so often that he 
can repeat it from beginning to end. That is a tough story, 
and I do not believe it myself, though I find it in this book of 
Forbes Winslow's. But there is no question that feats almost 
as marvellous have been accomplished. Think only of the 
way the Homeric poems were handed down from mouth to 
mouth of the ancient bards. How shall we go to work to dis- 
cipline the memory ? In the first place it is necessary to get 
a clear understanding of the thing to be remembered. The 
fault with most persons who say they have bad memories is, 
that they are deficient in power of attention ; they get no defi- 
nite conception of an idea, and so, of course, cannot recall it. 
Then, when if we understand the thing, begin to repeat it — 
not too often at once, for that is fatiguing, but recurring to it 
again and again. Lord Bacon said that if you would learn a 
sentence, you should repeat it ten times, twenty would only 
w^eaken the memory. That, in the aphasic condition, great 
improvement can be efiected by this means, I have found in 
several cases occurring in my own practice, two or three of 
which are still under treatment. One of the best methods. 



78 CLI]S"ICAL LECTUEES. 

after the patients have made some little progress, is to set 
them to ^vriting, and then they can pursue the exercise bv 
themselves. I have no doubt that, in this lady's case, if the at- 
tempt were made every day for a week to teach her to say one 
particular word, her own name for example ; following this 
by teaching another word in the same way, and then another, 
it would not be long before she would have quite a number at 
command. And then her progress would begin to be more 
manifest, and seem much more rapid. If it takes a stupid 
child three months to karn the letter A, it will take him less 
time to learn B, and far less to learn C, and he will have mas- 
tered the alphabet within a year. So, when Mrs. "W. has re- 
covered a hundred words, the rest will seem to come of them- 
selves. 

The use of the muscles of articulation in this persistent ex- 
ercise is the very best means of overcoming the remaining 
ataxia. We have also another means at our disposal to aid in 
dispelling any lingering paralytic element in the ataxia — the 
application of the induced or faradaic current to the affected 
parts. This you have seen quite successful in the case of Wice. 
We want, also, to enlarge the vessels of the brain, increase its 
blood-supply, and improve its nutrition. This object we shall 
seek to effect in two ways : first, by the passage of the con- 
stant galvanic current through the brain, applying the poles, 
one over each mastoid process, or one to the mastoid process, 
and the other to the back of the neck ; second, by giving phos- 
phorus, in the form of the phosphorated oil, five drops in emul- 
sion with mucilage three times a day. Under this treatment 
— as there is no evidence of present organic disease, beyond 
this headache, which is a little suspicious, and which I shall in- 
vestigate more closely — I have strong hope that she may get 
perfectly well. 

LECTUEE YI. 

FACIAL PARALYSIS.^ 

Gentlemen : We have before us to-day an example of 
facial paralysis, an important affection upon which I propose 

^ Phonographic report of Dr. John "Winslow. 



FACIAL PARALYSIS. 79 

to speak pretty fuHv. I introduce to yon a captain of the 
gallant Sixty-ninth Eegiment, who has been kind enongh to 
come here to-day, altliongh one of my private patients, and I 
will read the brief history of this case as drawn up by Dr. 
Cross : 

Facial Paralysis. — " Captain T. D., aged forty-three, born 
in Ireland. On awakening one morning in July he found 
something strange about his face, but did not realize at that 
time what it was. On going out, some of his friends told him 
that his face was twisted, and, on looking in the glass, he dis- 
covered that it was drawn to the left side. He applied for 
medical treatment, four days afterward, when he presented 
all the characteristic symptoms of facial paralysis. He was 
treated with galvanism, both the primary and induced cur- 
rents. In the course of a week he acquired the power of clos- 
ing his right eye voluntarily. He took strychnia and phos- 
phoric acid internally. After about twenty applications of 
galvanism he was dismissed with the power almost entirely 
restored to all the paralyzed muscles. He is now well, with 
the exception of slight paresis of the orbicularis oris muscle. 
At first the induced current did not act, whereas the primary 
did from the very beginning." 

This aifection, known frequently as '' Bell's paralysis," w-as 
for a long period confounded with some others. It is due to 
lesion of the facial nerve, the portio dura of the seventh pair, 
— a nerve formerly regarded as sensitive, and often cut for tic- 
doloureux, but established as strictly motor by the experiments 
of Bell and Magendie. Remembering the distribution of this 
nerve to nearly all the superficial muscles of the face, we can 
readily understand the symptoms which characterize its para- 
lysis. 

The most prominent of these symptoms is the inability to 
close the eye of the affected side, from the fact that the orbicu- 
laris has lost its nervous supply, while the levator palpebrse 
superioris, supplied by the third nerve, retains its power. 
The eye waters from being kept constantly open ; particles of 
dust get into it, for the patient cannot wink to keep them out. 



80 CLmiCAL LECTUEES. 

or to remove them from the surface of the eye-ball where they 
adhere ; the tears, for the same reason, are not distributed over 
the globe ; and they are not conveyed away through the nasal 
duct, from paralysis of the tensor tarsi, which should hold the 
funda against the globe to receive them, but flow over the 
cheek. From all these causes serious inflammation may arise ; 
but, if the patient is sensible, he will avert many of the evil 
consequences, by frequently closing the lid with the finger, or, 
if necessary, by keeping it closed with a strip of adhesive 
plaster. 

Again, one-half of the orbicularis oris is paralyzed, and so 
the patient finds it impossible to whistle or to spit. Indeed, 
he cannot even retain the saliva upon the afiected side, but it 
is constantly drooling out of the corner of the mouth, consti- 
tuting one of his greatest annoyances. Captain D. here, 
though almost completely cured, finds this muscle still so 
weak that, as you see, he cannot get the right pucker for a 
whistle. 

The buccinator, too, is paralyzed, and this interferes sadly 
with the comfort of chewing. The proper muscles of mastica- 
tion are supplied, as you know, by the third division of the 
fifth pair ; the jaws, therefore, continue to do their work well 
enough. But the buccinator has to assist the tongue in the 
important office of keeping the food between the teeth ; and, 
when it is paralyzed, this collects between the teeth and the 
cheek in a manner extremely disagreeable. This patient will 
tell you that he used to have to remove it with his fingers. 

The mouth, the whole face, in fact, is drawn over toward 
the sound side, for the muscles of that side find nothing to 
antagonize them. The effect of this is most marked when the 
patient opens his mouth, and particularly when he laughs or 
smiles, and brings the zygomatici and the risorius into play. 
Look on the affectecl side of the face, and it is utterly devoid 
of expression — a perfect blank, no matter what or how strong 
the emotion. There is not even a wrinkle of the brow, for the 
occipito-frontalis and the corrugator-supercilii have no power 
to contract. Romberg has humorously said there is no better 
cosmetic for old women. From the drawing of the face to the 



FACIAL PARALYSIS. 81 

sound side, the tongue, altliougli protruded directly forward, 
appears to deviate toward tlie side paralyzed. 

The facial nerve takes its origin from the posterior border 
of the pons Varolii, and the lateral tract of the medulla oblon- 
gata, some of the fibres of origin being traced to the floor of 
the fourth ventricle, and even to the lateral column of the 
cord. It is in reality, then, a spinal nerve, like some others 
which make their exit through the cranium. It is important 
that you should consider its course and its connections, for a 
knowledge of these often enables us to locate quite definitely 
the seat of lesion when it is paralyzed, and this has the great- 
est influence in determining our prognosis. Leaving the 
cranial cavity by the internal auditory meatus, it enters the 
aqueductus Fallopii, a canal hollowed for it in the petrous 
portion of the temporal bone, and finally emerges from the 
skull at the termination of this canal, the stylo-mastoid 
foramen. 

Of its branches of communication we will consider only 
three, all of them given off in the aqueductus Fallopii, 
namely, the two superficial petrosal nerves which arise from 
the gangliform enlargement of the facial soon after it enters 
the aqueduct, and the chorda tympani, which is given off from 
the facial just before it quits the canal : 1. The great super- 
ficial petrosal runs to Meckel's ganglion, and through this sup- 
plies the levator palati and azygos uvulse muscles. 2. The 
small superficial petrosal (which some regard as rather a branch 
of the glosso-pharyngeal, though communicating with the 
facial) runs to the otic ganglion, which supplies^ the tensor 
tympani muscles, and also, according to Bernard, through the 
auriculo-temporal, presides over the secretion of the parotid 
gland. 3. The chorda tympani goes to join the gustatory 
branch of the fifth, and is in part distributed with this to the 
tongue ; but another portion of its fibres enters into the sub- 
maxillary ganglion, which presides over the function of the 
submaxillary gland. 

• Thus far we have considered only the symptoms due to 
lesion of the facial after its exit from the stylo-mastoid fora- 
men. Let us now see what additional ones we shall have 
when the lesion is situated farther back. 



82 CLINICAL LECTURES. 

• First, let it be above tlie origin of the chorda tympani, but 
below that of the petrosals. The patient will complain of a 
diminution, but not a complete abolition, of the sense of taste 
upon the side of the tongue corresponding to the paralysis. 
This fact led to the supposition formerly that the chorda tym- 
pani was a sensitive nerve ; but the experiments of Bernard 
and others have clearly shown it to be an efferent nerve, car- 
rying influence from the brain, not to it. It is certain that 
one of its actions is to increase the flow of submaxillary sali- 
va ; it innervates the inferior lingualis muscle ; and it is prob- 
able that it also erects the papillae of the tongue, and modifies 
the circulation in thi^ organ. We can account, then, for the 
diminution of the sense of taste, when the influence of this 
nerve is cut off, by the dryness of the mouth preventing the 
speedy solution of the -sapid substance, by the want of erethism 
of the papillae, and perhaps also by the changed circulating 
conditions. 

'Next place the lesion back of the gangliform enlargement, 
between this and the meatus internus, we have, of course, all 
the symptoms thus far described, and, in addition, those due 
to the petrosal connections. One of these is a falling of the 
posterior palatine arch upon the affected side ; it hangs lower 
than its fellow, and its edge is nearly straight instead of con- 
cave. This comes from paralysis of the levator palati, which 
we found was supplied by the great petrosal through Meckers 
ganglion. One of the two little muscles of the uvula being 
powerless, the other contracts the uvula into a bow, concave 
on the sound side, toward which its point is directed. The 
uvula and velum are also pulled en masse toward the sonnd 
side, from paralysis of the opposing tensor (circumflexus) pa- 
lati, which, you will remember, ig supplied by the small pe- 
trosal through the otic ganglion. These deviations, at least, 
are what we should expect from our knowledge of the func- 
tions of these nerves, and they accord with the statements of 
most observers. Romberg, however, says that the uvula 
points to the paralyzed side. We shall not be surprised, from 
the connection of the small petrosal, through the otic gan- 
glion, with the parotid, to find the secretion of this gland 
much diminished, and, in some cases of intra-cranial lesion of 



FACIAL PAEALYSIS. 83 

tlie facial, tlie patient has complained of extraordinary drynesB 
of the affected side of the mouth. It is probable that we may, 
as stated by good authorities, have a real, and not simply an 
apparent, deviation of the tongue, some of whose muscles are 
said to be supplied by Meckel's ganglion. Another occasional 
symptom, increased acuteness of hearing on the paralyzed 
side, Landouzy accounts for by paralysis of the tensor tym- 
pani, which we found supplied by the otic ganglion; but 
Brown-Sequard attributes it to hypersemia of the acoustic 
nerve from vaso-motor paralysis. 

The diagnosis of lesions of the nerve yet more deeply 
seated — within the cranial cavity — must depend upon the 
concurrence of the symptoms of facia? paralysis, already noted 
with those of the affection of the nerves ; for a central lesion 
is not lils:ely to be limited to the origin or the tract of a single 
nerve. Just what symptoms we are to look for as diagnostic 
of the specific seat of a central lesion will be considered when 
we come to the subject of cerebral hgemorrhage. Some of 
them we have recently had occasion to observe in a case of 
cross-paralysis." 

Among the causes of facial paralysis I think the most com- 
mon is cold. The form of paralysis which it induces is that 
in which the nerve is affected only after its exit from the tem- 
poral bone. The case before you is one of that kind, and it 
most probably originated in this way, though its history is not 
clear. This cause often passes unrecognized, for the patient 
may show no other effect of exposure than the paralysis, as in 
the case of a young lady up-town, whom I was lately called 
to see. A very common history — one of which I have seen 
many examples — is, that the patient was sitting in a draught 
of air, say before the window of a railway-car, felt a little chilli- 
ness of the face, but thought nothing of it, sneezed a few 
times on going to bed, and awoke in the morning to find his 
face awry. 

Cold may produce its effects in two ways. The first is by 
directly depressing the irritability of the nerve, as when you 
paralyze the ulnar nerve by holding the elbow in ice-water. 
The second and far more common mode is, by exciting in- 

' PsYciroLo<sicAL JouENAL, Januaiy, 1871, ^vol. v., p. 14. 



84 CLINICAL LECTUEES. 

flammation and swelling, and consequent pressure upon the 
trunk of the nerve or its branches. You know that the facial, 
just after its emergence from the skull, passes for some distance 
through the parotid gland, so that any inflammatory swelling 
of this gland would almost certainly compress it. Inflamma- 
tion is especially apt to follow exposure in persons of a rheu- 
matic diathesis, whence this diathesis should be regarded as a 
predisposing cause. Rheumatic inflammation affects, as you 
are aware, the fibrous structures, among which are the sarco- 
lemma of muscles and the neurilemma of nerves. Inflamma- 
tory hypersemia and effusion in the first of these situations 
would compress the terminal filaments of the nerve ; in the 
second, might compress its fibres in any part of their course. 

But we may have pressure from other causes than inflam- 
mation. Women are fond of sleeping with the fsbce upon the 
closed hand, and they sometimes have to pay dearly for it by 
a loss of half their comeliness. IS'ew-born children delivered 
by forceps are not rarely found paralyzed from pressure of the 
instrument applied over the ear, especially if the extraction 
has been tedious. We may, of course, have various traumatic 
injuries in this region. 

Deeper-seated lesion of the nerve may arise from the press- 
ure of tumors of various kinds, from syphiKtic periostitis in 
any part of the aqueductus Failopii, from scrofulous disease of 
the middle ear finally destroying the bone, from gunshot or 
other fractures of the temporal bone, etc. 

The pathologi/ of the affection has been implied in its eti- 
ology, which resolved itself, in most cases, into one or another 
form of pressure upon the nerve, all producing essentially the 
same effect. You know that, by pressure on a nerve, its irrita- 
bility is more or less impaired. If you sit upon the edge of a 
chaii' in such a way as to press upon the sciatic, your leg and 
foot get numb, and you lose power over them. If you were 
not to change your position, you might thus produce perma- 
nent paralysis, for I have shown you more than one case of 
permanent paralysis of the arm from the patient's going to 
sleep with the arm thrown over the back of his chair, so as to 
compress the brachial plexus. 



FACIAL PARALYSIS. bD 

As Tfegards diagnosis, this affection is liable to be confound- 
ed witli one other, and onlj one, that is, paralysis from cere- 
bral hcemorrhage. In paralysis from haemorrhage the function 
of this nerve is hardly ever completely abolished. The pa- 
tient can always close the eye of the affected side, no matter 
how severe the hsemorrhage, though, why he should be able to 
do this when he cannot move the other facial muscles, I am 
unable to tell you. Then, too, other nerves will be found in- 
volved. If the h93morrhage be above the pons, we shall have 
paralysis of the extremities on the same side of the body as 
that of the face, that is, on the side opposite to the extravasa- 
tion ; or, if the haemorrhage be lower down, we may have 
cross-paralysis. The fifth nerve will be affected, and with it 
the muscles of mastication and the sensibility of the paralyzed 
side of the face. The third will probably be involved, and we 
shall have divergent squint, ptosis, and dilated pupil ; or the 
sixth, giving us convergent squint. According to the location 
and extent of the haemorrhage, we may have any or all of 
these symptoms combined. 

The prognosis in facial paralysis due to lesion of the nerve 
outside the skull is very favorable, if the case is seen early 
enough. Duchenne says that, w^hen the electro-motor con- 
tractility of the muscles is destroyed, it is hopeless to attempt 
to restore their function. And by this he means susceptibility 
to the induced current, which is the only one much employed 
in France, the primary current having been brought into thera- 
peutic use chiefly by the Germans. If Dnchenne's statement 
were correct, then the case before you would have been hope- 
less, and so would be at least three-fourths of those which come 
under our observation. For it rarely happens, even when the 
paralysis has lasted but a few days, that the faradaic current, 
as strong as you dare to apply it, will induce contraction in 
the affected muscles. In the captain's case here, only four 
days after the attack, it would not even cause a tremor. So 
far as my present experience goes, I should say that, when the 
muscles fail to respond to every electric stimulus, the progno- 
sis is very bad indeed ; but, if you get any reaction, however 
slight, from a strong interrupted primary current, you have 



86 CLINICAL LECTUKES. 

miicli reason to hope for success. Next year we may jmd some 
more powerful stimulus to muscular contraction, but tbus far 
we have nothing better than the galvanic current. 

We have seen how the duration of the affection, before 
treatment is begun, enters into the prognosis from the rapid 
diminution of muscular contractility. There is another way 
in which time becomes an important element. A secondary 
consequence of the paralysis is permanent contraction of the 
paralyzed muscles from atrophy, and of the muscles on the 
sound side from lack of their normal antagonism. After this 
kind of contraction has once set in, it will sometimes go on in 
spite of all treatment. It becomes of the utmost consequence, 
therefore, to institute the treatment before such contraction 
has commenced, and in this will depend in great measure the 
encouragement you can give the patient. 

When the lesion is deeper seated, the prognosis is, of course, 
less favorable, but even then it is greatly modified by the lo- 
cation and the cause. You cannot expect to remove an intra- 
cranial tumor, or to cure a necrosis of the temporal bone ; but, 
if the pressure on the nerve is due to a syphilitic periostitis in 
some part of its course through the bone, you may hope to re- 
move it by anti-syphilitic treatment. If, then, by the means 
already pointed out, you have located the disease in the acque- 
ductus Fallopii, and if, at the same time, you can trace a syph- 
ilitic history, you will be warranted in speaking far more fa- 
vorably than when a lesion so located cannot be referred to 
this as a probable cause. 

The treatment has been to some extent implied in what we 
have already said. Its indications are few and simple : to re- 
move the cause if possible, and put the nerve under the best 
conditions for regaining its lost power ; and to preserve the or- 
ganic integrity and irritability of the muscles until this can 
take place. 

Where we have reason to suspect a syphilitic, rheumatic, 
or gouty origin of the trouble — for gout has been said to pro- 
duce the affection, though I have never seen it — the causal in- 
dication may be met by constitutional remedies addressed to 
the diathesis. 



FACIAL PAEALYSIS. 87 

For the restoration of the nerve-function we can do little 
beyond secnriug healthy nutrition of the general system by 
proper hygiene, and by tonics if necessary. Yon will find by 
yonr text-books, however, that a great variety of means have 
been tried and are even now employed for the purpose of af- 
fecting the nerve. One of those most uniformly recommended 
is a blister along its course. I used to apply it, but I never 
saw it do any good. So, too, of liniments, they are utterly 
worthless. Strychnia applied endermically upon a blistered 
surface, or hypodermically over the paralyzed muscles, I have 
employed a good deal, but it is of little or no service in the 
first stage. Strychnia is an excellent tonic, however, and I 
have found it of value in improving the nutrition of the nerve 
after any presumably inflammatory action has passed off. It 
may be administered as above, in doses of one-thirtieth or even 
one-twenty-fourth of a grain ; or may be given by the mouth. 
This patient, after he had been under treatment about two 
weeks, got the following mixture, which brought up his appe- 
tite and strength: 9- Strychnige sul. grs. ij., acidi phosphoric! 
diluti, syrupi zinziberis, aa § ii. M. S. A teaspoonful three 
times a day. 

The third indication must be met by local means. The 
best* way to maintain the nutrition of a muscle is to exercise 
it ; and considerable advantage may be gained from such pas- 
sive exercise of the facial muscles as the patient may be in- 
structed to make by frequent pinching and kneading. The 
great means of exercise, however, and the only one we can de- 
pend upon, is the electric current, either the induced or the 
interrupted primary. The constant galvanic current, more- 
over, may be employed to improve nutrition by dilating the 
arterioles, and so increasing the blood-supply, apart from the 
muscular contractions produced by its interruption and re- 
newaL I am accustomed to try first the induced current, and 
if it excites muscular contraction there may be no necessity for 
resorting to the other. If there is no response to this, then we 
must have recourse to the primary. But the application of 
this latter to the face must be made with o;reat caution. Du- 
chenne destroyed the sight of one of his patients by using too 
strong a primary current in this situation. I never employ. 



88 CLIXICAL LECTUEES. 

unmodified, tlie current of more tlian about fifteen of Smee's 
or Bunsen's cells. ' But, by passing the current tlirougli a col- 
umn of water some three or foiu- inches in height, I have been 
able to use as many as sixty cells with safety. Whichever 
current you employ, you must secure its action upon every one 
of the paralyzed muscles ; and the best way to do this is to 
place one pole over the point of exit of the facial from the 
skull, and with the other (a moist sponge) stroke the whole 
side of the face. Do this three times a week. In the captain's 
case the primary current was required for about two weeks, or 
six applications, and then the induced current would act, and 
was used to continue the cure. As almost always happens, 
the fii'st muscle to recover its function was the obicularis pal- 
pebrarum. In the case of the young lady of whom I spoke, 
and whom I saw in consultation with Drs. Xott and Castle, 
the induced current acted from the first, and so I was able to 
prognosticate a speedy recovery. In about a week she ac- 
quu'ed the power of closing the eye, and yesterday I learned 
that she could already execute many movements on the para- 
lyzed side. 

This affection is somewhat liable to recur, and with each 
recurrence is a little more difficult to manage; but the princi- 
ples and the mode of treatment are precisely the same as in 
the first attack. 



LECTUEE YII.^ 

GLOSSO-LABIO-LAEYXGEAL PAEALTSIS. 

The case before us is an example of a, very interesting 
and very important disease, which, though it has undoubt- 
edly existed for a long time, has never been recognized as 
a distinct affection until within the last ten or twelve years. 
Some thirty years ago. Prof Trousseau was requested to ex- 
amine a distinguished personage of France, and made a 
memorandmn. of the phenomena observed, the chief of which 
were inability to speak, restraint in moving the lips, and ex- 

^ Phoiiograpliic Report of Dr. Jolin Winslovr 



GLOSSO-LAJBIO-LAEY]SraEAL PARALYSIS. • 89 

treme difficulty in swallowing. About twenty years later, 
Duclienne, knowing nothing of tliis memorandum, described 
very definitely the affection which I now bring before you, 
calling it progressive paralysis of the tongue, lips, and veil of 
the palate. Trousseau subsequently brought forward otlier 
cases, and delivered a very interesting lecture upon the disease, 
which he named glosso-laryngeal paralysis. He gave Du- 
chenne full credit for its discovery, while claiming for himself 
the prior observation of the single case above referred to, of 
which, however, his memoranda had been put aside and for- 
gotten. To Duchenne, therefore, belongs the credit of the 
discovery of the malady, as also of its latest working-up ; for 
he has recently gone over the ground again, changing the 
name to glosso-labio-laryngeal jparalysis. 

This is quite a rare affection. I have seen altogether, in 
this city, seven cases of it, before the present one, and this is 
less pronounced than any of them. Undoubtedly we have 
here the malady in its ineipiency, or at least in a very early 
stage, so that its physiognomy and symptoms are not well 
marked. Commonly these are so characteristic that you have 
no difficulty in pronouncing the diagnosis at once. I remem- 
ber that in the last case I saw — that of a banker from Kansas 
City, who had come on to consult Dr. Say re and myself, but 
in the doctor's absence had seen me alone — I was able to tell 
him what was the matter the moment he entered my office, 
and to describe his symptoms accurately without his help. 
That patient was unable to speak ; but, as in this case there 
was no impairment of the intellect. In all of my other cases, 
also, the patients could not speak a word at the time I first 
saw them ; and the paralysis of the lower face liad already 
advanced so far, that it remained as motionless as a mask, while 
the eyes and the muscles around and above them were full of 
intelligent expression. 

But before describing in detail the symptoms of this dis- 
ease, or considering its pathology, let me read you the elabo- 
rate history of the present case, which has been prepared by 
Dr. Cross : 

Case I. Glosso-Labio-Laryngeal Paralysis, — " W. H. 
S., aged thirty-two, born in I^ew York, married, the father 



90 CLINICAL LECTURES. 

of two children, both of whom are living ; a book-keeper by 
occupation. He has always been very temperate in his habits. 
There is no hereditary predisposition in his family to diseases 
of the nervous system. He has never had acute articular 
rheumatism, syphilis, nor in fact any disease of importance, 
until the beginning of the present trouble, which he dates back 
to the w^inter of 1867. Up to that time he had always been 
a tolerably healthy man, and even now he attends to his daily 
avocations, and does not consider his affection of much mo- 
ment. His father died of cholera some years ago ; his mother 
and her children are all living at the present time. His grand- 
parents on both his mother's and father's side w^ere very long- 
lived people, reaching the average age of eighty. 

" The first thing that attracted the attention of the patient, 
in the winter of 1867, was a peculiar sensation at the angle of 
the mouth, and the inner canthus of the eye on the left side. 
He says he felt like rubbing those parts continually. This 
sensation very slowly and gradually extended, and it was not 
until the winter of 1869, two years subsequently, that he be- 
came aware that not only his left cheek, but also his left temple, 
was very numb. At this period, while meditating over his 
accounts, he often struck his left cheek with the end of his 
pencil as one is very apt to do, when he was conscious of a 
very peculiar feeling w^hich would start from the point struck, 
and travel rapidly upward, terminating at the left temple. 
This numbness or ansesthesia remained limited to these parts 
on the left side for a period of several months, before any other 
perceptible change took place. There was also a loss of sen- 
sibility in the mucous membrane lining the left cheek and the 
gums on that side, which he had noticed from the very first ; 
he likewise chew^ed his food mostly on the right side, but at- 
tributed this more to the loss of feeling than to any want of 
power. Since 1867 he was aware that there was something 
wrong with his face, but he had no idea that there w^as any 
paralysis, and supposed the trouble to arise from the non-cut- 
ting of a wisdom-tooth on that side. At the time that the 
numbness had extended to the left temple, he experienced a 
feeling of constriction around the border of that eye, as thougli 
a tiojht rubber band were encirclino- it. Durins^ the month of 



GLOSSO-LABIO-LAEY]S'GEAL PARALYSIS. 91 

May, IS 70, the ansestliesia, wliicli was prior to this period 
limited entirely to the left side, began to extend, and progres- 
sively spread across the forehead, from the left temple to the 
cutaneous surface which circumscribes the right orbit, and to 
a small spot situated on the malar bone. !N"ow he had ring- 
ing in the left ear, which w^as subsequently followed by im- 
pairment of hearing, to such a degree that he was unable to 
hear the ticking of a watch, or to understand persons convers- 
ino' in a low tone of voice. 

"Durino; the ^dnter of 18G8 he had twitchino- of the left 
eyelid, which, after lasting for about a month, disappeared. 
In the month of September, 1870, the numbness again began 
to increase, and now attacked the parts about the naso-labial 
fissure on both sides, where it even now persists. It was at 
this period that his eyes became very much congested ; and 
this condition, although varying in degree from time to time, 
lasted for at least a month. The left, however, was much 
more congested than the right. Soon he experienced some 
difficulty in reading, and at times he could hardly read at all. 

" When the numbness had involved both naso-labial fissures, 
he noticed a stiffness about his mouth which resembled that 
peculiar want of natural mobility which is caused by exposure 
to extreme cold. For the first time he had slight difficulty in 
swallowing ; yet this was not caused by any interference with 
the act of mastication, for his food was well prepared, but sim- 
ply the first act of deglutition was not easily performed. For 
a year past he has been subject at times to vertigo, whenever he 
suddenly changed his position. When leaning forward, if he 
quickly raised up his head, he ])ecame giddy and had tempo- 
rary loss of consciousness, only for a few seconds, however ; and 
this occurred often many times in a day. Even on changing 
his position in bed he became dizzy. About a year ago he 
became aware that he could not walk very well in the dark, 
and especially with his eyes closed, yet he did not experience 
any diminution of motor power in his lower extremities. 
During the last three months he has had more or less trouble 
in making water, which did not come as freely as it used to 
do, and consequently he has been obliged to strahi in order to 
empty his bladder. There is no stricture or other cause o1 



92 CLINICAL LECTURES. 

obstruction in tlie iiretlira. Within the last two months he 
has had pain in the occiput and in the vertex, which would 
come on two or three times a day and last for about half an 
hour at a time. This pain was not very severe in character. 
Two months ago he noticed, while leaning forward in the act 
of wa-iting, that the saliva fell from his mouth drop by drop. 
He has very gradually lost his virile power, and he noticed this 
failure from the onset of the disease. Only within the last 
month has he become conscious of a slight embarrassment in 
his speech. 

^' Such is the history of this patient up to the 9th of January, 
1871, when he came under the observation of Dr. Hammond. 
The following points of interest were ascertained January 12, 
1871. Present condition : There is double facial paralysis, 
which is more marked on the left than on the right side of 
the face. The lower part of the face is immovable, while the 
upper is immediately thrown into action whenever the patient 
laughs or talks. There is at times twitching of the upper lip, 
and involuntary lifting of both upper eyelids, with a peculiar 
stare of the eyes, as though they were looking at vacancy. 
There is at present a feeling of constriction around both eyes. 
There are oscillatory movements of the eyeballs (nystagmus), 
which are in a lateral direction, and are almost constant. On 
this account, ophthalmoscopic exploration w^as not made. He 
lias double vision at times. "When he writes he is very apt to 
omit or misplace letters in many words, and in conversation 
he often miscalls or misplaces words. His memory of words is 
not perfect. He has pain still in the back and top of his 
head. There is no pharyngeal constriction. The first act of 
deglutition is imperfectly performed, yet it is not in the least 
painful ; and the patient described it exactly when he said, 
' When I want to swallow, it will not work.' The food col- 
lects between the cheek and the gums on the left side, but he 
can remove it with perfect ease by his tongue. He chews his 
food mostly on the right side, yet he can chew it very well on 
the left. At present he has very little vertigo. There is no 
nasal resonance in his pronunciation, and his friends do not 
notice any change in his voice. His pupils are exactly equal. 
It is difficult for him to look to the left, but he can turn his 



GLOSSO-LABIO-LARYiS^GEAL PARALYSIS. 93 

eyes to tlie riglit and see objects without any trouble whatever. 
On account of this he always takes a seat on the right side of 
a car in travelling. There is no strabismus, no ptosis, and at 
present only very slight conjunctivitis of the left eye. His 
nose is drawn to the right side, and the right nostril dilates and 
obeys the actions of its numerous muscles much more readily 
than the left. His mouth is dry, and the secretion of saliva is 
much diminished. In swallowing liquids he experiences no 
difficulty, but it is a great effort for him to swallow solids un- 
less he takes a quantity of fluid at the same time. In speak- 
ing he clips his words ; and although he can pronounce every 
letter in the alphabet, yet he does not evince in his enuncia- 
tion of the letters that clearness and distinctness of sound 
which he would undoubtedly have if he had full command 
over all the muscles concerned in articulation. There is much 
stiffness about the orbicularis oris. Occasionally, when leaning 
forward, the saliva falls from his mouth guttatim. There is 
no throbbing, no twitching, no tremulousness, nor deviation of 
the tongue. His tongue is perfectly mobile, and he can move 
it freely in any direction. His mouth is drawn to the right 
side ; yet he can open and shut it quite readily, draw it to one 
side or the other voluntarily, and compress the lips, but when 
he lauo-hs or talks in an animated manner its defective action 
immediately strikes the eye. He tires after talking, from the 
fact that his mouth becomes very dry. There is no feebleness 
whatever of the voice. The soft palate is relaxed, more espe- 
cially on the left side, and the natural arch is lost to a greater 
or less extent, while the uvula is drawn over to the right side. 

" Tactile sensibility is diminished in the mucous membrane 
of the tongue, hard and soft palate, the gums, cheek and lips on 
the left side ; in short, there is anaesthesia of the whole left side 
of the buccal cavity, which is limited exactly by the mesian line. 
Tactile sensibility is also diminished in those parts of the face 
where he felt the numbness, namely, on the left temple, around 
the left eye, and here to the greatest degree, around the right 
eye, on the malar bone, and here limited to a circumscribed 
spot, and lastly in the region of both naso-labial fissures. 
The sensation of pain is as acutely felt in all these external 
anaesthetic parts as in the healthy tissue, excepting in the cir- 



9-^ CLINICAL LECTUKES. 

cumscribed spot on the malar bone. There is impairment, if 
not actual loss, of taste, on the left side of the tongue. On the 
left side of the buccal cavity, the tongue included, the sensibility 
to pain by electricity is diminished. All the muscles of the 
face respond to the Faradaic current. He can whistle and 
expectorate, but he does not purse up his lips very strongly. 
Irritation of the soft palate does not produce normal contrac- 
tions, although it responds feebly to a stimulus. There is no 
atrophy of the tongue or of the lips. Tactile sensibility and 
the sensibility to pain are normal in all other parts of the 
body. With the exception of the regions already mentioned, 
there is no numbness nor abnormal sensation to be discovered 
anywhere. There is no trembling of the limbs. There is some 
difficulty of locomotion in the dark, and on first arising in the 
morning. "When his eyes are closed he oscillates from side to 
side, and if not supported ^would fall. He still has some 
trouble in passing his urine. In regard to spinal symptoms, 
with the exception of the want of coordination and the bladder, 
they are entirely negative. His intellect is perfectly clear, as 
evinced by his great quickness of comprehension and ready 
intelligence. His heart and lungs are healthy. He sleeps 
well. His appetite is good. His bowels are regular. His 
pulse is 68, slow and full. His respiration is full, deep, and 
regular. There is no paralysis nor even paresis of the limbs, 
so far as can be ascertained. He can close quite perfectly both 
eyes simultaneously, or he can close one at a time. The larynx 
rises quickly and naturally, and the second act of deglutition 
is normally performed. The lips, on attentive observation, are 
seen to have lost their ready play or tonicity, and the angle 
of the mouth on the right side is thrown into action to a much 
greater extent than the opposite angle. That innate contrac- 
tility which resides in the different facial mnscles, and on 
whose normal tension and irritability depends the faculty of 
expression, is greatly impaired about the mouth and the whole 
lower part of the face on both sides. The muscles at the right 
angle of the mouth and on the right side of the face respond 
to a weaker Faradaic current than on the left. He can blow 
with sufficient force to put out a candle, but the current of air 
is imperfectly directed, owing to the lack of the harmonious 



GLOSSO-LABIO-LAEYIs^GEAL PARALYSIS. 95 

action of tlie muscles of the month and lips. His general 
health is at the present time so good that he thinks, if it were 
not for the slight difficulty which he experiences in swallow- 
ing, and his impairment of coordination, he would be as 
well as he ever was in his life. The treatment in this case 
consists in the internal administration of strychnia as follows : 
!p . Strychnise sulphatis gr. j, quinine sulphatis et ferri pyro- 
phosphatis aa 3j, acidi phosphorici diluti Jli? syrup, zingi- 
beris § ij. M. S. A teaspoonful in a wine-glass of water three 
times a day; together with the application of the primary 
Galvanic current to the base of the brain three times a week, 
and the application of the induced, or Faradaic, current to all 
the muscles of the buccal cavity, the lips, and the muscles of 
expression which are involved in the disease. The patient has 
now been under treatment about a month, and during that 
period the disease has made very little, if any, progress in its 
onward course." 

Such, gentlemen, is the history of this very interesting and 
instructive case. Let us note the order in which the symp- 
toms have made their appearance, and we shall find it differ 
decidedly from that usually observed in the disease. 

The first thing which attracted the patient's notice was 
ansesthesia of a portion of the left side of the face and buccal 
cavity, not loss of motility. That shows that there was prim- 
arily implication of the trifacial nerve on that side. 'Now, 
in every other case which has come under my observation or 
my reading, the starting-point was in the hypoglossal, as in- 
dicated by loss of motility in the tongue. By reference to 
these diagrams upon the board, you see that the fifth nerve 
has its superficial origin at the anterior part of the side of the 
pons Varolii; and the fibres of its sensory root, which at 
present concern us, have been deeply traced to nuclei in the 
medulla oblongata, on the floor of the fourth ventricle. I have 
no doubt that, in this case, the disease originated in these 
nuclei. 

The next nerve involved was the auditory — the eighth of 
Sommering ; he lost, to a great extent, the sense of hearing on 
the left side. The auditory nerve, which you see leaving the 



96 CLn^ICAL LECTUEES. 

pons posterior to the iiftli, lias, like that, its deep origin in 
the floor of the fourth ventricle. I think we have clearlj the 
right to conclude that the disease, which commenced in the 
nuclei of origin of the fifth nerve, graduallv extended until it 
involved those of the eighth. 

Still progressing, the disease next invaded the origin of the 
facial (seventh of Sommering), the great motor nerve of the 
muscles of expression. For we find the patient complaining 
of a feeling of stijffness about the lips, a little want of play in 
the orbicularis oris — a muscle supplied, as you know, by the 
facial. This nerve leaves the pons close to the auditory (so 
that the two were formerly classed together as the seventh 
nerve), its fibres being traced to the outer wall of the fourth 
ventricle, and to the restiform and olivary tracts of the me- 
dulla. The partial paralysis, first perceived in the lips, ex- 
tended later to some of the neighboring muscles ; the buccina- 
tor,, for example, began to refuse duty, and allowed the food to 
get between the gums and the cheek. You see that the gentle- 
man holds his lips slightly open, and when he is leaning for- 
ward, intent on his work, the saliva sometimes drops from 
them. But he tells me that it does not flow from his mouth 
at night, which is rather surprising ; for many persons with 
no facial paralysis find their pillow wet in the morning. It is 
especially apt to occur from the general relaxation of the 
muscles in old age. 

About this time, or somewhat earlier, there was some 
twitching of the left eyelid, and afterward a feeling of con- 
striction about it. ]S"ow, twitching of the lid I used to suppose 
was always caused by spasm of the levator palpebrse superio- 
ris, supplied by the third nerve. But having it badly myself 
at one time (I do now when I smoke too much), I watched 
the movements carefully before the glass, and was not a little 
relieved to find they were not such as would proceed from an 
implication of the third nerve — for this nerve comes from the 
crus cerebri, an ugly spot to have trouble with. I saw that 
the movement was not directly upward and downward — the 
only one possible from the action of the levator — ^but was 
rather a twitching downward and inward, and evidently 
caused by spasm of some fibres of the orbicularis palpebrarum. 



GLOSSO-LABIO-LAEYNGEAL PAEALYSIS. 97 

pulling the upper lid toward their origin at the tendo ocnli. 
This muscle is supplied by the facial ; and it need not surprise 
us to find, as in the present case, irritation of some of the fibres 
of this nerve at their origin preceding or accompanying the 
partial paralysis of other fibres (e. g., those distributed to the 
orbicularis oris). You will recollect, too, that Dr. Cross speaks 
of an involuntary raising of the lids. This likewise does not 
result in the present case from any spasm of the levator pal- 
pebrse superioris, but from slight convulsive action of the oc- 
cipito frontalis, a muscle also supplied by the facial nerve. 

The nystagmus and double vision, it is true, might lead 
as to suspect some difficulty with the third pair, resulting 
in weakness of the internal rectus and that intermittent, trem- 
ulous action which weakened muscles are apt to display. 
Taking it in connection with the early twitching of the lid, a 
superficial observer would perhaps diagnosticate at once a 
partial paralysis of the motor oculi communis. But if that 
were the case, we should expect also ptosis by this time, and 
dilatation of the pupil, neither of which is present. There 
would very likely, also, be some interference with the functions 
of the superior and the inferior rectus, while in fact the patient 
can hold his eyes pretty still when he looks straight forward. 
To what, then, must we ascribe this lateral oscillation of the 
eyeballs, which is so strongly marked when he tries to look to 
one side ? It can be due only to spasm or paralysis — probably 
the latter — of one or both of the external recti ; and, as he can 
turn his eyes easily to the right and with difficulty to the left, 
it is doubtless the left external rectus which is weakened. 
These muscles are supplied by the sixth pair of nerves, which 
you see taking origin, close to the pons, from the anterior pyra- 
mids of the medulla oblongata, and which may be traced to 
the floor of the fourth ventricle. 

There is in this case no paralysis whatever of the tongue, 
that is, the hypoglossal is not yet involved, that nerve arising 
lower down than those we have seen affected. Whence, then, 
the difficulty of swallowing ? It must come simply from want 
of power over the palatal muscles (levator palati, azygos uvulae, 
and tensor palati) supplied by the facial, through the spheno- 
palatine and otic ganglia. Indeed, these muscles are seen on 



98 CLINICAL LECTUEES. 

inspection to be relaxed on the left side ; and tlie di-yness of 
the mouth indicates that the parotid gland, which also derives 
its supply from the otic ganglion, has lost something of its 
functional activity. There seems, then, to be no trouble in 
the medulla oblongata lower down than the deep origin of the 
facial. Neither the pneumogastric nor the spinal accessory 
has suffered, so that there is no interference with regular and 
complete respiration, or with phonation. The man's voice is 
as strong as ever, and he can blow his breath with much force, 
while in no other case I have seen could the patient blow out 
a candle. 

Some of the symptoms, as the attacks of vertigo and of 
pain, suggest cerebral difficulty ; but the man's intelligence is 
unimpaired, as evinced by his quick and clear answers to my 
questions, and, if there be any organic disease of the brain, I 
am unable to make it out. I think we are justified in exclud- 
ing structural lesion, and attributing these symptoms to some 
derangement of the cerebral circulation. 

The patient, as you see, cannot, with his eyes shut, either 
stand still or walk steadily across the floor, but keeps swaying 
from side to side ; and he says that he cannot walk in the dark. 
You have seen this symptom in two cases which came before 
you at a previous lecture, and we-then found it dependent upon 
a loss of the sense of pressure and of sensibility in the soles of 
the feet.' This loss of sensibility is frequently due to an affec- 
tion of the posterior columns of the cord, as in locomotor ataxia, 
but not invariably, for you get the same symptom when the 
feet are " asleep," for example, from cold, or from pressure on 
their nervous trunks. In the present instance there are prob- 
ably independent centres of trouble in the sensory tract of the 
cord, as evidenced not only by the want of coordination in 
walking without the aid of sight, but also by some awkward- 
ness the patient finds in buttoning his collar, doubtless from 
diminished sensibility in the fingers. The difficulty in evacu- 
ating the bladder also points to some morbid condition of the 
cord. 

Thus, we have gone over the main points in the history 

^ Psychological Jouexal, Jaauary, 1871, p. 31. 



GLOSSO-LABIO-LAEYNaEAL PAEALYSIS. 99 

of the case before us, and, in order to sliow tlieir connection, 
I have been obliged to anticipate to some extent its pathology. 
The patient may now be dismissed ; while, to complete onr 
pictnre of the disease, I must rapidly sketch those features 
which om- model does not exliibit. 

As I have said, the tongue is commonly first affected. The 
23atient discovers that he cannot clearly articulate the linguo- 
dental consonants. A little later he is unable to raise the tip 
of this organ to the roof of the mouth, or to employ it to keep 
the food between the teeth in mastication. Soon the first act 
of deglutition becomes difficult — the alimentary mass cannot be 
readily carried back and pressed against the constrictors of the 
pharynx ; and finally the tongue lies utterly inert on the floor 
of the mouth. By this time the lips have begun to suffer ; 
they tend to remain apart, and the saliva dribbles from them ; 
the vowels o and u cannot be distinctly sounded ; whistling 
and spitting become impossible. Then other muscles supplied 
by the facial partake in the paralysis — the buccinators, the 
elevators of the palate and of the uvula, and the tensors of the 
palate ; and swallowing becomes harder than ever, the food 
being often forced from the pharynx back into the mouth, or 
ejected through the nose. By-and-by the pharyngeal constric- 
tors themselves can no longer be trusted — the pneumogastric 
and spinal accessory are becoming involved. When these 
nerves are still further affected, we find the power of phonation 
lost, and that of respiration seriously impaired, from paralysis 
both of the glottic muscles and of those fixing and moving the 
ribs. Every attempt to swallow is now attended with imminent 
danger of suffocation, from portions of food or drink entering 
the larynx, and the impossibility of coughing vigorously to 
throw them out again. A fatal bronchitis or pneumonia may 
thus be set up ; or, if the patifent escape these, as well as all 
the chances of strangulation, he dies at last of inanition. 

Thus, in what has heretofore been regarded as the typical 
form of the disease, we have simply progressive motor paraly- 
sis, in muscles innervated by the hypoglossal, the facial, the 
pneumogastric and the spinal accessory (partly through the 
pharyngeal plexus), and lastly by some of the spinal nerves — 
for the phrenic and even the intercostal nerves seem to be some- 



100 CLIXICAL LECTURES. 

times affected. Trousseau tells iis that sensibility is wholly 
intact, and that even the reflex imtability of the paralyzed 
muscles is retained. 

[N^ow, the case we have to-day been examining, and one 
other which has come under my observation, enable me to say 
that there is another type of the disease, in which the primary 
symptom is loss of sensibility, attended sometimes by hyperal- 
gesia, the motor paralysis not appearing until later. I And, 
also, on a careful review of Trousseau's cases, that one of those 
is to be placed in the same category. 

There is no doubt that this disease was for some time con- 
founded with progressive muscular atrophy, or Cruveilliier's 
atrophy, as it is often called — a malady characterized by pro- 
gi'essive wasting of the affected muscles, and by their weak- 
ening in consequence of this wasting, not in consequence of 
deficient motor innervation. It so happens that in several 
reported cases the two affections were coincident ; that is, 
there was motor paralysis of the parts we have been consid- 
ering, with atrophy of some muscles of the trunk and limbs. 
These two conditions are sufficiently distinct. In the one we 
have primarily paralysis of motihty, and only such subsequent 
atrophy of the muscle as results from its disnse. In the other 
we have primarily atrophy of the muscle, and only such loss 
of power as this necessarily entails. But Trousseau, on the 
basis of several post-mortem examinations, considered that their 
association in the cases referred to was something more than 
accidental. For the chief lesion found in these autopsies was 
atrophy of the roots of those motor cranial nerves we have 
enumerated, and of the motor roots of some of the spinal nerves. 
He suggested, therefore, that glosso-laryngeal paralysis and 
progressive muscular atrophy were only varieties of a palsy, 
dependent upon an affection of the cord or of the medulla ob- 
longata, whose chief anatomical expression was this atrophy of 
motor roots. 

It was reserved, however, for the searching eye and the 
fertile brain of Duchenne, only a few months ago, to proclaim 
at once the facts and the theory which should exliibit the rela- 
tion between these affections, and mark a great advance in our 
nervous pathology. The paper was published in Brown-Se- 



GLOSSO-LABIO-LAEYISTGEAL PAEALYSIS. 101 

qnard's Archives for Angust, 1870. You know that every- 
where ill the nervous system the gray or cellular matter is con- 
sidered to be the source of nervous power, while the white 
matter is held to be only its conductor. Now, Duchenne's 
theory is, that there are at least three distinct kinds, or sets, of 
cells, the exclusive function of one set being to preside over 
sensation (sensory cells) ; that of another set to preside over 
motion (motor cells) ; that of a third set to preside over nutri- 
tion (trophic cells). Each set of cells has its own exclusive 
conducting fibres ; but the motor and trophic sets are apt to 
lie near each other, and their conducting fibres to go together 
in the same bundle (or "nerve"), while those of the sensory 
set often take an independent course to their distribution. The 
anterior roots of the spinal nerves, for example, start probably 
from both motor and trophic cells, the posterior from sensory 
cells alone. There are no microscopic distinctions as yet made 
out between these functionally difierent sets of cells, though it 
is not impossible that such distinctions may in future be dis- 
covered. The theory of their functional difference is an in- 
ference which physiology draws from the data furnished by 
pathology. 

What are these data ? In a post-mortem examination of a 
patient who had suffered profound atrophy of the tongue and 
facial muscles, and had died from some other cause, Duchenne 
found that not only were the roots of the hypoglossal, facial, 
and some other motor nerves much, shrunken at their emer- 
gence from the brain and cord, but the cells about the deep 
origin of these nerves had, to a great extent, disappeared, and 
been replaced by connective tissue. In some places he could 
even count the cells in connection with the nerve-root, and in 
one instan(;e there were only nine or ten to be found. Of what 
kind were the missing cells ? Though the microscope could 
give no answer, yet the fact that the effect of their disappear- 
ance was not paralysis, but atrophy of the organ supplied by 
their nerves, clearly pointed to them as trophic cells alone. 
Similarly, had the medulla oblongata presented precisely the 
same appearances, and the history of the case shown not a di- 
minution in the size of the muscle supplied, but simply a lack 
of nervous motive power, he would have been warranted in 



102 CLII^ICAL LECTURES. 

supposing that it was the motor cells which had sufFered de- 
struction. And so, if a certain number of cells and the sensi- 
bility of a peripheral area having nervous connection with 
them, had disappeared together, we should justly regard it as 
presumptive evidence of a genetic relation -between them. 

I^ow, if the lesion, resulting in destruction of nervous cells, 
be of centric origin — for example, if it be a sclerosis due to 
chronic hyperaemia or inflammation — it is extremely unlikely 
that it would affect only one of two or more sets of cells lying 
in close juxtaposition. "We should expect, therefore, to find 
motor paralysis and muscular atrophy in frequent companion- 
ship; and this, as I have said, is really the case, the same 
muscles being both palsied and atrophied. We shall see, how- 
ever, when I come to speak more particularly of wasting palsy, 
that it seems frequently to have a peripheric origin, in over- 
exertion of the affected muscles, and consequent exhaustion of 
their nervous centres ; and in such cases we often find no 
primary motor paralysis. "When, as in the case you have just 
seen, the trouble begins with paralysis of sensation, we should 
hardly look for attendant atrophy; and in point of fact, in this 
case, there is no atrophy whatever, as both Dr. Cross's examina- 
tion and my own have distinctly proved. Still, we have muuh 
to learn concerning the etiology of nervous lesions before we 
can hope for a wholly satisfactory explanation of the apparent 
anomalies of association which sometimes occur. 

You have already divined that not only the forms of pa- 
ralysis which chiefly concern us to-day, but others as well, are 
explained by this theory of the disappearance of central nerve- 
cells having special functions. Thus, locomotor ataxia, which 
our patient exhibits in some degre6, and the characteristic 
lesion of which is sclerosis of the posterior columns of the cord, 
falls into the same category. So, too, with " essential," or, as I 
have termed it, organic infantile paralysis, which depends upon 
destruction of both motor and trophic spinal cells. 

With reference to the causes of glosso-labio-laryngeal pa- 
ralysis very little is known. The course of several diseases, 
however, shows that there are two radically distinct forms 
of centric cell-destruction in general, the one acute, the other 
chronic. In the first, of which organic infantile paralysis may 



GLOSSO-LABIO-LAETNGEAL PAEALYSIS. 103 

serve as tlie type, the invasion is sudden, and the affection 
may become fully developed in a few hours, after which it pro- 
gresses very slowly, if at all. In the second, the invasion is 
very gradual, and the disease is essentially progressive, the 
cells probably undergoing a slow absorption. To this form 
belong glosso-laryngeal paralysis, progressive muscular atrophy, 
progressive locomotor ataxia, and so on. ]!!^ow, upon the mat- 
ter of etiology, it has been definitely ascertained that the 
chronic form may be inherited, but the acute shows no such 
tendency to hereditary transmission. 

Age seems to exert a predisposing influence on the develop- 
ment of the disease in question. The present patient is the 
youngest, on record, to manifest it, being but thirty-two years 
of age ; and I have seen it positively stated that the disease 
never appears under the age of forty-five. In this case, indeed, 
I am unable to discover any probable cause. 

One of my patients, a very small man, fifty years old, dated 
the origin of his malady to some one's coming up behind him 
and lifting him by his head, " to show him London." I have 
seen a number of instances where incurable affections were 
brought on by this same silly trick. 

The prognosis is wholly bad. Our patient, comfortable as 
he now appears, has scarcely a possible chance for recovery ; 
for, of some forty cases of the disease fully reported, every one 
has gone on steadily, or with only slight remissions, to a fatal 
termination. Of the seven cases which have come under my 
own observation before the present, but one is alive — the Kan- 
sas City banker — and he only because he has not had time to 
die. I have sent him home, with the unfavorable prognosis 
which I always give. 

There is no need, then, of my dwelling upon the question 
of treatment. I tell patients frankly there is no use in it ; and 
for only one of my former cases have I attempted to do any 
thing with any hope of cure. That was my first one, a gen- 
tleman sent me by Dr. Bradley, of this city. I applied gal- 
vanism to the muscles of the tongue and throat for three or 
four weeks, and it certainly did effect something. The man 
got so that he could swallow quite well, but the improvement 
was only temporary, and soon the current ceased to elicit any 



104 CLINICAL LECTUEES. 

response. In a few other cases the dysphagia has been miti- 
gated for a time by like means. I am treating Mr. S. here 
with the galvanic current passed through the brain, and the 
medulla oblongata, and the Faradaic current to the muscles of 
the face. He is also taking phosphorus and strychnia. These 
are the only means that promise to be of any service, and, if 
a patient insists upon being treated, you may employ them 
to give him a transient respite or to alleviate his distress. 



LECTUEE YIII. 

CEEEBEAL HEMORRHAGE. 

There is no aifection, in the whole range of diseases of the 
nervous system, which it is more important that you should be 
thoroughly acquainted with, than that which I propose to con- 
sider to-day, and which, so far as its symptoms are concerned, 
has been confounded until very recently with a number of differ- 
ent cerebral affections. By cerebral hsemorrhage is understood 
that condition which is due to the rupture of a blood-vessel, and 
the consequent extravasation of blood either into the substance 
of the brain, or into its ventricles, whereas the term apoplexy is 
generally applied to sudden causes, however induced, and con- 
sequently embraces a large number of diseases ia which the 
prominent symptom is loss of consciousness. Formerly medical 
writers were in the habit of grouping together, under the term 
apoplexy, several different affections, but a better knowledge of 
the subject has taught us to separate and distinguish these from 
each other, so that embolism, thrombosis, meningeal haemor- 
rhage, and many other diseases, are readily diagnosticated from 
cerebral hsemorrhage. There are two forms of this affection, 
which are called the apoplectic and the paralytic, and which 
differ from each other in this respect, that, in the former, the 
mind is suspended in its action, whereas, in the latter, there is 
no loss of consciousness, although the mind does not generally 
act with its accustomed vigor after the attack. 

Having thus briefly called your attention to the topic upon 



CEEEBKAL H^MOEEHAGE. 105 

Tvliicli I shall lecture to-day, in these few preliminary remarks, 
I will now proceed to read the history of the following case : 

Case I. Cerebral HoemorrTiage. — "Eliza Gr., forty years 
of age, single, was born in !N"ew York City, and is a washer- 
woman by occupation. About five years ago she had a very 
severe attack of typhus fever, after which she found that her 
eye-sight was more or less impaired, and that her hearing, 
memory, and intellect, were also somewhat affected. Prior to 
this, however, she had been a very healthy woman, and had 
always been remarkably temperate in her habits. She has 
never had syphilis, gout, nor acute articular rheumatism, but 
for some time past she has complained of shortness of breath, 
and great precordial distress on taking violent exercise, such 
as running up-stairs quickly or otherwise unduly exerting her- 
self. For the last three months she has suffered from violent 
attacks of asthma, which have troubled her very much. Her 
mother, when about sixty years of age, was paralyzed on one 
side of her body, and her speech was much affected. Although 
she lived for several years after this attack, she never com- 
pletely recovered from her hemiplegia, nor did she ever regain 
the normal use of the faculty of speech. A brother, at the age 
of sixteen, was suddenly seized with loss of consciousness, and 
died in the course of two hours afterward. During this attack 
he had no convulsive movements whatever, and he never ral- 
lied from his apoplectiform condition. He had, however, or- 
ganic disease of the heart. 

" The first symptom which attracted the attention of this 
patient occurred about the 3d of October, 1870, at which time 
she was suddenly seized with a violent pain across the fore- 
head, which returned at intervals for a period of at least two 
weeks before she was paralyzed. October 17th, as she was 
engaged in washing, leaning over the edge of a tub in a con- 
strained position, she suddenly felt very dizzy, and her sight 
grew misty and dim ; she left her tub and reeled across the 
room, but was almost immediately supported and placed in a 
chair. For a short space of time, her ideas were much con- 
fused, but during the attack her consciousness was unim- 
paired. 



106 CLIIS-ICAL Li:CTUEES. 

" On endeavoriiig to speak slie foimd that lier speech was 
verj much impaired, and it was with verj great difficulty 
that she could make her wishes known to her friends. Mo- 
bility on the right side was lessened, while tactile sensibility 
was also diminished. The muscles of the face were drawn 
to the left side, while the tongue pointed toward the right. 
There was internal strabismus of the right eye. The patient 
came to the Out-door Department of the New York State 
Hospital for Diseases of the N'ervous System, October 24th, 
just one week after the attack, and walked up the steps with 
very little assistance. At this time she complained of pain in 
the back of the head, and constipation of the bowels. She 
was directed to go home immediately, keep perfectly quiet, 
and guard against all undue efforts, such as leaning over to 
tie her shoes, straining in the water-closet, etc. Aloetic 
pills were prescribed to regulate her bowels, and she did not 
return to the hospital for treatment until November 10th, 
when I learned that the pills had had the happy effect of caus- 
ing the pain in the head to disappear as soon as they had op- 
erated. Her condition was now as follows : owing to the pa- 
ralysis of the tongue, the lips and cheek on the right side, her 
articulation is rather indistinct, yet by attention you can un- 
derstand what she says very well. Her face is drawn to the 
left side, and the angle of the mouth drops on the right, from 
which the saliva everv now and then dribbles. Her tongue 
deviates very slightly toward the right side. The pupils are 
both equal, and there is at present no strabismus. Her eye- 
sight, hearing, memory, and intellect, have been more or less 
impaired ever since she had typhus fever, but she thinks that 
they are no worse at present than they were before this attack. 
Motility is much more impaired in the face than in the arm, 
and it is also more impaired in the arm than in the leg. She 
staggers occasionally after any considerable amount of exer- 
tion. Tlie right cheek is flaccid and puffs out at times, while 
the food lodges in the cavity thus formed, to the great incon- 
venience of the patient. The muscles of the tongue are im- 
peded in their normal movements, and consequently she ex- 
periences some difficulty in protruding that organ. The mo- 
tility of the right arm is now very slightly diminished, and she 



CEREBRAL HEMORRHAGE. 107 

is able to execute complex movements with it very well in- 
deed. The right leg slie raises well from the ground, the toe 
does not catch ; and if it were not for a slight circnmdnction of 
the foot in walking, her gait would attract little attention. 
The tactile sensibility is equal on both sides of the body, w^hile 
the muscular contractility, and the sensibility to electricity, 
are slightly diminished on the right side. Slight differences 
in temperature and the sensation of pain exist between the 
two sides. There is a suspicious-looking ulcer on the right 
leg, which has not yet healed. She displays no undue emo- 
tional excitability. Her heart was examined, and found to be 
healthy ; the physical exploration of the lungs was made, but 
unfortunately the result was not recorded. Ophthalmoscopic 
examination of the eyes at this time revealed nothing abnor- 
mal. 

" All the diseased muscles respond well to the Faradic or 
induced current ; those of the face, however, requiring a 
stronger stimulus than those of the arm, and those of the ami 
a stronger stimulus than those of the leg." 

Such, gentlemen, is the history of this very interesting case, 
which affords us a good example of the paralytic form of the 
disease now under consideration. 

The first symptom which this patient noticed was a violent 
pain in the forehead, which was present at intervals for two 
weeks prior to the attack, and which pointed to cerebral diffi- 
culty. You know that in cerebral hoemorrhage there are a 
number of premonitory symptoms which are generally present 
for a variable period prior to the full development of an attack, 
and that these phenomena show a disturbance in the cerebral 
circulation. In some cases we have severe headache, as is 
well illustrated in the patient before us ; in others we find dif- 
ficulties in speech, which are due either to slight paralysis of 
the tongue, to paralysis of the cheek and lips, or other muscles 
concerned in articulation, or else are dependent upon a want of 
coordination in the muscles of speech, or there may be defects 
of sight, or numbness limited to one side of the body, which 
is not an uncommon occurrence, as several cases of this kind 
have fallen under my observation. Or there may be simply 
vertigo, with confusion of ideas, and specks before the eyes, 



108 CLmiCAL LECTUEES. 

whicli may precede tlie attack by only a few seconds, and be 
the only admonition which the patient has. Even in those 
instances in which there are premonitory symptoms, the attack 
takes place suddenly, as it did in the present instance. But, 
generally, there are present only those symptoms which occur 
directly before the attack, and which show both mental and 
physical disturbance. 

When an individual is attacked with the paralytic form 
of cerebral hsemorrhage, he is perfectly aware of his condi- 
tion, and soon discovers that his arm and face are affected, 
and that his speech is unintelligible. If, however, he be 
sitting or lying down, instead of standing, he does not dis- 
cover that he is paralyzed until he attempts to rise. In a 
case of a distinguished officer of the army, after a fatiguing 
day of ceremony, who was returning in his carriage to his 
hotel, as he passed along Fifth Avenue, he suddenly expe- 
rienced an indescribable sensation, and then became aware 
of the fact that he could only see the half of objects. He 
did not lose consciousness, although when he arrived at 
the hotel, and attempted to get out of his carriage, he found 
that he was paralyzed on the right side, and that his speech 
was so much impaired that he could not make himself under- 
stood. In the case of this woman, who is now before us, the 
attack came on suddenly, and in a very short time involved 
the whole of the right side of the body. Her speech was so 
much affected that it was with great difficulty that she could 
make herself understood. Her face was drawn to the left 
side, which shows that the muscles of the right side are para- 
lyzed, and that their antagonists still act in a perfectly nor- 
mal manner. When the face is involved, scarcely any distor- 
tion is perceived when the patient does not attempt any facial 
movements ; but if he endeavors to open his mouth, to spit, or 
to puff out the cheeks, the paralysis is at once evident. In 
the majority of cases of cerebral hsemorrhage, we find that the 
facial paralysis soon disappears, together with the difficulties 
of speech, while the arm and leg still remain paralyzed. 
The mind becomes more active, and the affected limbs more 
capable of motion. Usually the leg recovers power much 
more rapidly than the arm, so that the patient can generally 



\ 



CEEEBEAL H^MOEEHAGE. 109 

walk very well long before lie can raise bis arm from bis side, 
bend bis elbow, or extend bis fingers. Tbe paralysis in tlie 
leg is particularly marked in tbose muscles wbicb extend tbe 
foot, and tbis gives rise to a peculiar gait, in order tbat tbe 
patient may clear tbe toes from tbe gronnd. Tbis is accom- 
plisbed by means of tbe abductor muscles, wbicb are rarely 
affected. Wben tbe patient walks be tbrows tbe leg out from 
tbe body by means of tbe muscles of tbe tbigb, so as to pre- 
vent dragging bis toes on tbe ground. 

Besides tbese disorders of motility, sensibility is more or less 
affected. Tbe limbs on tbe affected side feel beavy as if made of 
lead, and after a wbile disordered sensibility is experienced by a 
feeling as if pins and needles were sticking into it, or as if tbe 
limbs were asleep, or as if ants were crawling over tbe skin, or 
water trickling over it. In Eliza G.'s case you will observe tbat 
tbe improvement took place first in tbe leg, tben in tbe arm, 
tben in tbe tongue, and lastly in tbe face. We generally find, 
bowever, tbat tbe difficulty in speecb and tbe loss of power in 
tbe muscles of tlie face disappear before tbe paralysis of tbe 
extremities. You will observe too, tbat tbere was external 
strabismus on tbe rigbt side, wbicb sbows tbat tbe tbird 
nerve was partly paralyzed, so tbat tbe abducens still act- 
ing rotated tbe eye outward. Tbe bsemorrbage, wbicb in tbis 
case was on tbe left side of tbe brain, must bave been small in 
amount, as tbe paralysis speedily disappeared, and left bebind 
only tbe implications of tbe face and tbe muscles of tbe tongue. 

You also notice, from tbe bistory of tbe case, tbat tbe pa- 
tient came to tbe bospital one week after tbe attack, and tbat 
sbe was advised to go bome and to keep perfectly quiet, until all 
signs of irritation of tbe brain bad disappeared, wben it would 
be proper to commence treatment. I prescribed aloetic pills 
in order to move ber bowels, w^bicb were constipated, and ad- 
vised tbe patient to delay active measures to restore tbe power 
of motion until two or tbree weeks bad elapsed. A clot in 
tbe brain is to all intents and purposes a foreign body ; as tbis 
cannot be removed excepting by certain fixed and definite 
cbanges, it is necessary to sustain all tbe powers of tbe system 
in order to promote tbe absorption as rapidly as possible, and 
tbis is accomplisbed by keeping tbe patient perfectly quiet. 



110 CLINICAL LECTUEES. 

with the head well elevated, the room cool and thoroughly 
ventilated, and other indications should be met as they arise. 
After the lapse of two or three weeks we should commence to 
take active measures to restore the power of motion, and to 
prevent those contractions which tend to make restoration 
much more difficult. This we will try to do by hypodermic 
injections of strychnia, in doses of a thirty-second of a grain 
every alternate day, and by the use of the induced current, as 
this is found to cause contractions of the muscles on the dis- 
eased side until they are fully restored. 

[[N'oTE. — The treatment in this case has consisted solely in 
the application of the Faradic current to all the muscles which 
were involved in the disease on every alternate day, and in 
the course of six weeks improvement had taken place to such 
a degree that the patient ceased coming to the hospital. At 
the time of her discharge there was a slight paresis of the 
muscles of the right leg, which depended upon a weakened 
condition of the extensor muscles, which had not yet regained 
their tone. The right arm had almost entirely regained its 
normal vigor. There was still some slight difficulty of speech, 
but this depended more upon the paralysis of the facial mus- 
cles than upon the impairment of the muscles of the tongue, 
for the former was even now well marked, while the latter 
had nearly disappeared.] 

Case II. Cerebral HcBmorrhage with Left Hemiplegia. — 
" Joseph E. Pope, sixteen years of age, was born in JSTew York, 
and is a soap-manufacturer by occupation. When eight years 
old he had an attack of acute articular rheumatism, which 
lasted about six weeks. Every autumn since then he has been 
troubled more or less with severe seizures of subacute rheu- 
matism, which would persist for a variable period, and then 
readily disappear under the use of the iodide of potassium. 
Subsequently he had shortness of breath and violent palpita- 
tion of the heart whenever he took any violent exercise what- 
ever, and this has been a very great discomfort and source of 
annoyance to him. He has no hereditary predisposition to 
diseases of the nervous system. In ^N'ovember, 1869, while 



CEREBEAL HEMORRHAGE. Ill 

stooping over to tie his shoe, he was suddenly seized with an 
intense pain in the right frontal region, accompanied with ver- 
tigo, dimness of vision, and general confusion of ideas. Loss 
of consciousness rapidly supervened, the patient falling for- 
ward, but before striking the floor he was caught by his 
brother. He remained completely unconscious for at least 
an hour, and, after he had revived and regained to some 
extent his senses, his left side was found to be completely 
bereft of motility and sensibility. The face was drawn 
to the right side and the tongue deviated. He was unable 
voluntarily to close his left eye. His speech was thick and 
indistinct, owing to paralysis of the muscles of the tongue. 
He was confined to his bed for the period of a month, after 
which he became able to move about a very little with assist- 
ance. Improvement in speech took place first, and the leg 
followed next in order. At the end of six weeks he was able 
to go about without any support whatever. After the lapse 
of three months the muscles of the face and tongue had en- 
tirely regained their normal contractility, but the leg and arm 
were still very much impaired. He was treated about this 
time daily by means of a weak induced current, but with very 
little benefit, so far as he was able to judge. He was ad- 
mitted to the Out-door Department of the New York State 
Hospital for Diseases of the Nervous System, September 26, 
1870, at which time he was in the following condition : 

" Motility is greatly impaired on the left side of the body, 
yet the muscular power is much more deficient in the arm 
than in the leg. The left upper extremity hangs by his side 
quite powerless, and the only motion which he can give to it 
is a slight lifting of the humerus by means of the muscles 
of the shoulder. The thumb is drawn into the palm of the 
hand, and the fingers are rigidly flexed upon it. In fact, mo- 
tility in the left upper extremity is almost nil. The hand 
cannot grasp the dynamometer, owing to its extreme rigidity. 
His left foot is adducted to a very great degree, and in walk- 
ing he swings it in the arc of a circle, and even then he stubs 
his toe at nearly every step, from ^he weakness of the exten- 
sor muscles. There is much atrophy of the muscles of both 
the arm and the leg, but more particularly the former. The 



112 CLIIS^ICAL LECTUKES. 

tactile sensibility, and sensibility to pain, are normal on tbe 
diseased side, while tlie sensations of heat and cold, and mus- 
cular contractility, are more or less diminished. The tempera- 
ture is also diminished on the diseased side. The bladder and 
rectum are normal ; the urine is healthy and acid in reaction. 
His memory and intellect are somewhat enfeebled. There is 
no difficulty whatever at present in closing the right eye vol- 
untarily. He has had only this one attack, and neither before 
nor subsequently to it has he had any head-symptoms what- 
ever. Physical exploration of the heart shows that this or- 
gan is hypertrophied, and that there are both mitral and aor- 
tic organic valvular lesions. The lungs are healthy. The 
pupils are equal and respond readily to light. Ophthalmo- 
scopic examination shows that the optic disks are in a healthy 
condition, and that the retinal circulation is normal." 

This case is particularly interesting from the fact that it is 
very difficult to decide definitely whether it be one of embo- 
lism or cerebral hsemorrhage, although I am inclined to the 
belief that it is a case of cerebral haemorrhage ; nevertheless, 
without a jpost-mortem examination, no definite opinion can 
be given. The attack came on in a young man only seven- 
teen years of age, who had had acute articular rheumatism, 
which was subsequently followed by disease of the heart, 
which gave rise to organic lesions both mitral and aortic. 
The attack was, however, apparently induced by strong mus- 
cular exertion while stooping over to tie his shoe. In a case 
of partial or complete hemiplegia, with or without loss of 
consciousness which occurs in a patient under forty years of 
age, with the hemiplegia on the right side, no muscular con- 
tractions and organic disease of the left side of the heart, 
with or without previous attacks of acute articular rheuma- 
tism, we may safely predict that the cause of these phenomena 
is cerebral embolism. The cause of the paroxysms, which we 
can justly attribute to the constrained position of the patient, 
the lesion being on the right side of the brain, while the re- 
sultant paralysis was on the left side of the body, the marked 
muscular contractions which have lasted already several 
months, and the subsequent improvement in the arm and leg, 



CEREBKAL H^MOREHAGE. 113 

all favor the view that the patient is suffering from an extrav- 
asation of blood into the right hemisphere much more than 
thej point to embolism. In embolism contractions never 
take place, and if the paralysis does not disappear within 
three days after the attack, it does not gradually fade away as 
it so often does in cerebral haemorrhage. Then, again, there 
was a short premonition in this case, as was shown by the pain 
in the head, the vertigo and confusion of ideas, symptoms which 
indicate haemorrhage rather than embolism, for in this latter 
affection there are no premonitory symptoms. 

You are aware that advanced age is the most influential 
circumstance which predisposes to an attack of cerebral hsem- 
orrhage, and this fact has been recognized ever since the days 
of Hippocrates. It is much more apt to occur in persons over 
forty years of age than in persons under this age, although 
the number of the latter is, comparatively speaking, very 
small. Of two hundred and twenty-nine cases of cerebral 
haemorrhage which have fallen under my professional charge 
within the last '^Ye years, two hundred and four occurred in 
persons over forty years of age, while the remaining twenty- 
iive cases were in persons under that age. Of these, seventeen 
were attacked between thirty and forty, seven between twenty 
and thirty, and one, the patient before you, is only seventeen 
years of age. This is the youngest patient that has fallen un- 
der my observation, w^ho was afflicted with cerebral haemor- 
rhage. There is another point in this case to which I wish to 
call your particular attention, and that is the difficulty which 
the patient experiences in closing his left eye voluntarily. 
You remember that Dr. Cross piirticularly mentions that fact 
in the history of Pope. In facial paralysis of cerebral origin 
the muscles of the face are incapable of expression, and are 
usually paralyzed on the side opposite the lesion, excepting in 
some rare instances in which the paralysis of the face is on the 
opposite side to that of the body, and the orbicularis-palpe- 
brarum muscle remains unaffected, the patient being able to 
close the eye ; whereas, in simple facial paralysis, this muscle 
is always involved, and consequently the eye remains wide 
open. It is from this circumstance that we are able to diag- 
nosticate a cerebral from a peripheral paralysis. Although 



114 CLINICAL LECTUEES. 

this patient is quite certain that lie could not close the left eye 
for some time after the attack, yet at present you see that he 
can do so with the utmost ease. He has not had any irritation 
of the left eye, as he undouhtedly would have had if there had 
been much loss of power in the orbicularis muscle, and it had 
remained thus involved for any considerable length of time. 
You who have seen many cases of facial paralysis will remem- 
ber that the patient is unable to close the eye on the affected 
side, and, in consequence of this condition, the eye is continu- 
ally exposed to the action of the atmosphere and the many 
particles of matter which are constantly floating about in it. 
The patient is also unable to wink, and, as a result, the tears, 
instead of being distributed over the sm-face of the eyeball, or 
carried away by the nasal duct, run over the lower lid upon 
the cheek, which they keep in a continual state of irritation, 
while the eye is constantly exposed to the particles of dust 
which accumulate upon its dry surface, and there remain on 
account of the loss of power in the constrictor muscle of the 
eye, whose function is thus impaired. The present case does 
not, however, invalidate the general law that, in facial paraly- 
sis of cerebral origin, the orbicularis-palebrarum muscle is not 
involved, and the patient can close the eye on the affected 
side. All writers upon diseases of the nervous system have 
noted this fact, and have called attention to it as the diagnos- 
tic point between facial paralysis of cerebral and peripheral 
origin ; nevertheless, in some rare cases this muscle is partially 
involved, but never to the same degree as in simple facial pa- 
ralysis ; and it is doubtless owing to this circumstance that the 
eye does not become inflamed, inasmuch as the muscle is not 
sufl&ciently affected to deprive it from partially performing its 
proper function. 

You also observe the marked contractions which exist in 
the muscles of Pope's left arm. I will now call your attention 
to the position of the upper extremity in well-marked cases 
of cerebral haemorrhage in which there is almost invariably a 
disposition toward contraction of the pectoralis major and 
minor muscles, so that the arm is drawn across the front of the 
chest. At the same time the latissimus dorsi, the trapezius, 
the rhomboidei, the teres major and minor muscles, are gener- 



CEEEBRAL H^MOERHAGE. 115 

ally in a state of relaxation, and eventually tend to atrophy. 
The elbow is slightly flexed, the wrist bent upon the forearm, 
and the fingers drawn in toward the palm of the hand. In 
some instances the thumb is drawn in to the palm of the 
hand, and the fingers are so rigidly flexed npon it that it is 
impossible to extend them, and the palm of the hand is lacer- 
ated by the sharp nails impinging against its surface. It is a 
curious fact, however, that the muscles of respiration are 
never aflected in cerebral haemorrhage unless the medulla ob- 
longata be involved. You remember that this patient was 
completely unconscious for an hour, and then gradually re- 
gained his senses ; so that you have here an example of the 
apoplectic form of cerebral haemorrhage in which the patient 
falls, is comatose, breathes stertorously, the lips and cheeks 
puff out with each expiration, the pulse is slow and full, the 
pupils are dilated, sensibility and the power of motion are 
abolished on one side of the body. The bladder and rectum 
are generally not affected. In a short time consciousness 
commences to return, and you can arouse him from his condi- 
tion of insensibility. He now attempts to move, though with 
diflSculty, and tries to speak. Articulation is, however, indis- 
tinct, for the muscles on one side of the face are paralyzed 
and the tongue, for a like reason, is restricted in its move- 
ments. If the patient be now examined, paralysis will be 
found to exist in the limbs of the same side, and involve the 
loss of sensibility, as well as of motion, although rarely to 
the same degree, as the former is less affected than the lat- 
ter. In the case of Eliza G-., the paralysis of the arm and leg 
rapidly disappeared, and at the time of her discharge there 
remained only paralysis of the face on the affected side, and 
some difficulty of speech. 

In the patient before us, although nearly a year has elapsed 
since the onset of the attack, yet we find no embarrassment of 
speech, no facial paralysis, no difficulty in closing the right eye ; 
but there still remains great loss of power in the left upper ex- 
tremity, the fingers of which are so firmly flexed into the palm 
of the hand that the patient is unable to grasp the dynamome- 
ter so as to measure the amount of loss of power upon that side, 
and the only motion which he can give to his arm is through 



116 CLINICAL LECTUEES. 

the muscles of the shoulder, by means of which he is able to 
move this member to a slight degree from the side of his body, 
■which fact shows that even the muscles of the shoulder are visi- 
bly affected. The lower extremity is not only much impaired, 
but its nutrition has also suffered as is shown by the atrophy 
in that part. The temperature on the affected side is also 
diminished, as is generally the case in these affections, and, al- 
though tactile sensibility is now normal, yet the sensations of 
heat and cold are still impaired. 

The mental characteristics of a patient will also be found to 
have undergone a radical change. He is irritable, unreasona 
ble, and fretful. His sense of the proprieties of life, which in 
health may have been very delicate, becomes obtuse. His 
memory is notably impaired, and his reasoning powers greatly 
diminished. But the greatest change that will be perceived 
will be found in the emotional faculties. He will laugh when 
he should cry, and he will shed tears at the veriest trifle — and 
this characteristic will remain for years. In Pope, the mem- 
ory and intellect are both found to be impaired, although not 
to a very marked degree, and his emotions have also undergone 
a radical change, as you will observe a circumstance in no de- 
gree ludicrous whatever will readily excite his mirth. Even 
in this case in which there are such well-marked contractions, 
and so great a loss of power upon the affected side, we can 
hope for marked improvement by a proper course of treat- 
ment, although in all cases of cerebral haemorrhage a patient is 
neither mentally nor physically the same after an attack as be- 
fore it, yet in some cases he may regain to a great extent his 
mental and physical health. I shall advise in the treatment of 
this patient the use of hypodermic injections of strychnia in 
the same manner as I have mentioned in the former case, and 
the employment of the primary galvanic current until the con- 
tractility of the muscles is so far restored that we may judi- 
ciously make use of the induced current. 

[Note. — February 16, 1871. The patient at this time was 
in the following condition : There had been a progressive and 
gradual improvement in both the upper and lower extremi- 
ties — the leg, according to the general rule, commencing to 



CEREBRAL HAEMORRHAGE. 117 

improve first, and in this respect it lias excelled tlie arm in its 
progress. The foot was only a little addncted, and there was 
less inclination on the part of the patient to swing it as much 
as formerly. The muscles responded well to a weak Faradic 
current, and were very much better nourished than they were 
when he first came under observation. He could use his leg 
very well, as evinced by his ability to walk long distances 
with greater ease ; his toes still caught occasionally ; the 
fingers, although weak, were supple, and he was able to give 
to them a certain degree of motion. He could grasp an ob- 
ject when put into his hand, and could flex his forearm upon his 
arm, touch his nose or the top of his head with his left hand 
with facility. At this period he passed from under my obser- 
vation.] 

The treatment has consisted in the application of the pri- 
mary galvanic current to the diseased muscles until they were 
susceptible to the induced current, when the latter was substi- 
tuted for the former. These applications were made three 
times Sii w^ek, and at the same time a hypodermic injection of 
the sulphate of strychnia, varying in amount from the forty- 
eighth to the thirty-second of a grain, was also given on every 
alternate day, p7^o re nata. This course of treatment was 
steadily pursued for over a year with beneficial results. Dur- 
ing the month of October the diseased side, which had been 
ansesthetic, became much more sensitive to electricity than 
the sound side, and this hypersesthesia, after lasting about two 
months, disappeared. T. M. B. C. 



LECTUEE IX. 

CEKEBEAL HJ2M0RRHAGE.— HEMATOMA OF THE DURA MATER. 

CEREBRAL THROMBOSIS WITH CROSS-PARALYSIS. 

In the previous clinical lectures I have presented you with 
three good examples of cerebral hsemorrhage, in .one of which 
there was cross-paralysis witli left hemiplegia ; in another the 
whole of the right side of the body was involved, while in the 
last case the paralysis was limited to the left side of the body. 



118 CLUS-ICAL LECTUEES. 

In all of these patients the face has also been affected, and in 
the last two we have fonnd more or less embarrassment of 
speech, with impairment of the muscles of the tongue. I will 
to-daj, gentlemen, continue this interesting subject, and speak 
to you more fully upon certain points which I was obliged to 
omit in the last lecture ; but before doing this I desire to call 
your attention to another instructive example of this disease, 
the history of which has been prepared by Dr. Cross. This 
patient is the wife of the man who was present at a former 
clinic when I spoke to you upon the subject of cross-paralysis ; 
and, while she is paralyzed upon the right side, her husband is 
paralyzed upon the left. 

Case III. Cerebral HcBmorrhage with Bight Hemiplegia. 
— "Elizabeth Ann Fetter, thirty- eight years of age, was born 
in New Y'ork City ; is married, and the mother of fourteen 
children, of whom live are at present living. Her mother and 
father both died of consumption. Her husband is hemiplegic 
on the left side of his body. She has never had syphilis, acute 
articular rheumatism, nor is she predisposed to diseases of the 
nervous system through any hereditary tendency. She has 
always been a remarkably strong, robust woman, enjoying the 
best of health, with the exception of attacks of dimness of vi- 
sion, mist before the eyes, and other perversions of sight, to- 
gether with transient spells of vertigo, which, during the early 
part of the year 1863, occurred at more frequent intervals than 
usual, although for a year or two previous to this time she had 
been subject to them. She has no disease of the kidneys 
whatever. In March, 1863, she had bilious remittent fever, 
and while convalescing from this she suddenly lost the power 
of speech. There was no loss of the memory of words, no de- 
fect in the faculty of coordination, but simply a paralysis of 
certain muscles used in the act of speaking. There was no 
paralysis of the limbs, nor of any other part of the body, ex- 
cepting the muscles of the tongue. For two hours she was 
totally unable to utter a single intelligible word, but with 
great effort she could give vent to strange and hideous sounds. 
After having been freely bled she suddenly regained the nor- 
mal faculty of speech. This attack took place just two weeks 



CEEEBEAL HJEMOEEHAGE. 119 

prior to lier confineinent, wliicli was natural in every respect. 
For two years subsequent to this slie enjoyed her own good 
health, having occasionally, however, slight cerebral conges- 
tive attacks, which were characterized by pain in the head, 
vertigo, ringing in the ears, disturbances of vision, etc., but 
not attended by loss of consciousness. In March, 1865, while 
stooping over in a constrained position washing the floor, she 
suddenly became dizzy, felt very much confused in regard to 
her ideas, could not see, and cried out, ' I am paralyzed.' Her 
husband, who was near at hand, caught hold of and supported 
her, otherwise she would have fallen. She was placed in bed, 
and shortly after examined, when it was discovered that the 
right arm and ]eg, together with the tongue, were very much 
paralyzed, and that tactile sensibility was unaffected. There 
was no paralysis of the muscles of the face, no strabismus, no 
ptosis, no difference in the size of the pupils, which were nor- 
mal. After this seizure the patient was confined to her bed, 
and in the course of a week was delivered of a fine girl. At 
the end of the third week she could just speak intelligibly 
enough to make her wants known, and in a short time she was 
able to move about by means of a chair, by which she sup- 
ported herself. The leg began to improve very slowly indeed, 
and after the lapse of two years the arm still remained per- 
fectly useless ; her speech was quite indistinct, and her lower 
extremity was so much impaired that she was able to go about 
with difficulty. Six weeks prior to her confinement, which 
occurred in the month of June, 1867, after a violent attack of 
vomiting, she was again paralyzed. This was evident from a 
sudden increased difficulty in talking and a greater degree of 
paralysis in the leg. Although this attack was much less se- 
vere than the former, and the head-symptoms were very slight, 
it was, nevertheless, well marked. In the course of three 
weeks the low^er extremity began to improve, then her speech ; 
and for a considerable time this gradual progress continued, 
until, arriving at a certain point, it stopped. Her arm has re- 
mained about the same, or at least it has not recovered suffi- 
cient power to be of the least possible use to her. She gave 
birth to three children after this last attack, two of whom are 
alive and well, while the third died, when six months old, of 



120 CLIlSriCAL LECTUEES. 

cliolera infantum. !N^one of them had convulsions. The pa- 
tient was admitted to the Out-door Department of the New- 
York State Hospital for Diseases of the Nervous System, Oc- 
tober 5, 1870, when she presented the follo^ving points of in- 
terest : 

'^ There is right hemiplegia involving the arm, leg, and 
tongue. The right upper extremity hangs powerless by the 
side of the patient, and seems perfectly devoid of motor power, 
yet the fingers are supple, and there is no tendency to rigidity 
or flexion. She is able to walk, if her hobbling gait can cor- 
rectly be called walking. There is the extreme swinging of 
the foot in a circle, and the constant dragging of the toes. 
Owing to a greater degree of paresis of the peronei and exten- 
sor muscles than that of their antagonists, the foot is adducted, 
and there is produced a variety of talipes very similar to that 
which is known as equino-varus. There is no paralysis of the 
muscles of the face, no deviation of the tongue, no ptosis, no 
strabismus, and no paralysis of the muscles of the lips. The 
tongue is not very mobile, and, although she can move it in 
any direction, it is not accomplished with that ready facility 
which it ought to possess in its normal condition. She does 
not speak very plainly, and there is a tendency to clip her 
words, which is quite noticeable. There is no stammering or 
hesitation in her speech such as is found in the ataxic form of 
aphasia. There is merely a thickness or indistinctness of ar- 
ticulation which arises from a loss of motor power in the tongue. 
There is no loss of the memory of words, nor are there any 
constant disturbances of the intellect. The special senses are 
unaffected. The cerebral congestive attacks still recur, but 
are not so frequent as formerly. There is no atrophy of the 
muscles perceptible on the diseased side, and, as regards their 
size and fulness, there is no difference between the two sides ; 
although mascular contractility is greatly impaired, it seems 
as though there is a corresponding lack of nervous energy in 
the diseased parts. The tactile sensibility is natural on the 
affected side, as are also the sensations of pain, heat, cold, etc. 
The bladder, rectum, and urine, are in a normal condition. 
The heart and lungs are healthy. There appears to be no 
marked loss of control over the emotions. The intra-ocular 



CEREBRAL HAEMORRHAGE. 121 

appearances were not noted, the eyes not being examined by 
the ophthahnoscope." 

In this case we have presented to ns many interesting phe- 
nomena which differ from those which we have found hereto- 
fore. Yon will observe, in the first place, that the face was 
not affected in the two attacks from which this patient suf- 
fered, although the arm, the leg, and the tongue, on the right 
side, were involved, nor was there any impairment of tactile 
sensibility upon the diseased side. You know that in cere- 
bral haemorrhage the paralysis may include the whole of one 
side of the body, or it may be limited to some particular mus- 
cle or sets of muscles. For instance, I have seen several cases 
in which the loss of power was confined solely to the leg, 
others in which the arm alone was involved, and still others in 
which either the tongue or the muscles of the face were par- 
alyzed. Then, again, the disordered cerebral manifestations 
existed in the present instance for a long period before they 
culminated in an actual attack, in which there was an effusion 
of blood in the brain-tissue. The difficulty in speech which 
this patient experienced was not, in my opinion, due to cere- 
bral hsemorrhage, for, if this had been the case, it would not 
have disappeared so suddenly ; but it is rather to be attributed 
to a sudden increase of blood to the brain, which was speed- 
ily relieved as soon as a sufficient amount of blood had been 
withdrawn from that organ. You will also observe that there 
were two well-marked attacks, which Avere separated from 
each 9ther by an interval of over two years, and that these 
were both preceded by indications of increased cerebral circu- 
lation, w^hich are very common precursors of cerebral hsemor- 
rhage. In the case now under consideration you will notice 
that excessive physical exertion was the cause of the attacks, 
and consequently I consider the prognosis much more favor- 
able than if it had supervened without any obvious exciting 
cause, for in that case we should have suspected in all proba- 
bility that the cerebral vessels were seriously affected. In the 
four cases which I have lectured upon this winter, you will 
recollect that the attack was caused, in all of them by exces- 
sive muscular exertion, excepting in the case of Fetter, whose 
paralysis came on during sleep. 



122 CLIXICAL LECTUEES. 

In this connection I will briefly enumerate the most potent 
canses of cerebral haemorrhage, to which I have not already 
called yom.' attention. The disease is much more common 
among men than among women, although some authors have 
denied this fact. Then, again, there is su23posed to be a special 
apoplectic constitution, but this has never been proved, as per- 
sons of sanguine temperament and plethoric habit are no more 
liable to cerebral haemorrhage than persons differently consti- 
tuted. One of the most common predisposing causes is un- 
doubtedly hereditary predisposition. Of the exciting causes, a 
long list can easily be mentioned, and chief among these is sea- 
son, for statistics show that the disease is much more prevalent 
in winter than at other times. TVhatever tends to increase the 
flow of blood to the head, or to retard its exit, is capable of act- 
ing as an exciting cause of cerebral haemorrhage, and under this 
head we embrace excessive mental and physical exertion, strong 
emotional disturbance, the excessive use of alcoholic liquors, 
straining in the water-closet, tight clothing around the neck 
or abdomen, childbirth, vomiting, sneezing, and coughing, ex- 
posure to great heat, the fact that a patient has had a previ- 
ous attack, and certain diseases, as syphilis, typhus fever, 
etc. 

In regard to the prognosis, we should take into consideration 
the extent of the haemoiThage, and the probability of saving 
life during the time of the attack and immediately afterward. 
In the apoplectic iormpa/' excellence of cerebral haemorrhage, 
death almost invariably takes place within a few hours. In 
the less severe form of cerebral haemorrhao;e which is attended 
with unconsciousness, and of which the case of Pope affords us 
an example, the prognosis depends upon the strength and age 
of the patient, and the conditions which produce the attack : 
thus in his case we should expect a favorable prognosis on ac- 
count of his age, there being no organic disease of the blood- 
vessels of the brain, the attack being induced by severe mus- 
cular exercise while in the act of tvins: his shoe. Ton must 
also take into consideration the number of attacks, for the 
second is more apt to prove fatal than the first, and the thii'd 
than the second. In the mild form of cerebral haemorrhage 
with paralysis, which is not accompanied with loss of con- 



CEEEBEAL H^MOEKHAGE. 123 

scioiisness, tlie prognosis is very favorable especiallj^ after the 
lapse of eight days, when all risk of inflammation has passed. 

In regard to the prospect of recovery fi*om the paralysis, 
much depends upon the length of time that the condition has 
lasted, the opportmiities which the patient has had for treat- 
ment, and whether strong contractions have taken place. In 
nearly all cases improvement takes place spontaneously, but 
after a while it stops, and then it is necessary to employ treat- 
ment if we hope to obtain amelioration. The extensor mus- 
cles of the upper and lower extremities are as a general rule 
the last to yield to treatment, and, even after all signs of pa- 
ralysis have disappeared in the rest of the body, these still re- 
main in a weakened condition. Even in cases where the 
amount of the haemorrhage is small, the intellect may suifer 
to a great extent ; in other instances the difficulties of speech 
may persist for a long time, as is illustrated in the case of Mrs. 
Fetter, although as a general rule these speedily disappear. 
Not only may the embarrassment of speech arise from pa- 
ralysis of the tongue, the lips, or the face, as we have seen in 
some of the preceding cases, but they may be dependent upon 
the loss of the memory of words, or an inability to coordinate 
the muscles concerned in articulation. Again, all signs of pa- 
ralysis may disappear in all parts of the body excepting the 
face, g,3 we saw in the case of Eliza Gannon. 

Hespecting the pathology of this affection I wish to say a few 
words. In the majority of cases it will be found that the cere- 
bral arteries are impaired by a disease which has been described 
by Yirchovv, and which was called by him chronic endoarteritis. 
This condition is induced by age or other influences which 
impair the nutrition of the cerebral vessels, although I believe 
that it is possible for a blood-vessel to rupture without its coats 
being at all diseased, in consequence of an increased tension of 
the blood or disease of the perivascular tissue. You are aware 
that the' brain-tissue is less resistant than that of any otlier 
organ in the body, and consequently its vessels are not as 
firmly supported as in other structures. If the perivascular 
tissue be diseased, the natural support of the vessels is still 
further lessened and the tendency to haemorrhage is increased. 
Then, again, we must take into consideration that certain dis- 



124 CLmiCAL LECTURES. 

eases, siicli as typlius fever, syphilis, rheumatism, scurvy, chlo- 
rosis, and the like, which impair the general nutrition of the 
body, may also affect the blood, so that the cerebral vessels 
are not properly nourished. In the four cases which we have 
studied, you remember that one had suffered from typhus 
fever, two from bilious remittent fever, and one from rheuma- 
tism, and it is perfectly possible that these different diseases 
so affected the integrity of the cerebral vessels that their tis- 
sue was more readily broken down than it otherwise would 
have been if their nutrition had not thus been impaired, and 
consequently a less degree of tension was required to cause 
their rupture. 

ISToTE. — [The treatment in this case has consisted in the 
application of the primary galvanic and Faradic currents to 
the diseased muscles, and to the trunks of the principal motor 
nerves every alternate day together witli a hypodermic injec- 
tion of the thirty-second of a grain of the sulphate of strychnia 
three times a week. 

October 22, 1870. — The symptoms of cerebral congestion 
having connnenced to make their appearance to-day, the patient 
was ordered to take fifteen grains of the bromide of potassium 
well diluted in water, three times a day, together with the ap- 
plication of the primary galvanic current to the head every 
alternate day. 

October 2Sth. — The induced current having commenced to 
produce contractions in both the arm and leg, this was alter- 
nated with the primary galvanic. The muscles of the arm 
respond much better to the induced current than those of the 
leg. 

October Slst. — The extensor and peronei muscles of the 
loot on the diseased side have improved to such a degree that 
they can be stimulated by a weak galvanic current. The 
muscles are pliable, and the toes can be moved by means of a 
strong Faradic current. 

December 17th. — All the muscles are now readily excited 
by means of Faradism. The patient being unable longer to 
come to the hospital on account of her domestic duties, pur- 
chased a small Kidder's induction-machine, which she now 



HEMATOMA OF THE DURA MATER. 125 

uses at home. When last seen, in January, 1871, her leg had 
markedly improved, and she was able to walk very well ; her 
speech was much more distinct, and she could move her tongue 
with greater ease ; her arm had not improved iu the same pro- 
portion as her leg, nevertheless some amendment had taken 
place. She could raise it from her side, and partially flex the 
forearm upon the arm, and she was also able to move her 
fingers voluntarily, but not to any great degree. The bromide 
of potassium had had the happy effect of causing the cerebral 
symptoms to disappear, and, after continuing its use for a 
period of three weeks, she was directed to stop using it. Sub- 
sequently these phenomena again made their appearance, and 
she was directed to continue the use of the bromide of potas- 
sium as long as they persisted. In January she informed me 
that she had ceased taking the remedy for some time, and that 
her head-symptoms had entirely disappeared. — T. M. B. C] 

h^mato:ma of the dura matee. 

This peculiar form of meningeal hemorrhage is the result ot 
a chronic inflammation which takes place on the under surface 
of the dura mater, and is generally situated in the neighbor- 
hood of the sagittal suture, so that it involves both hemi- 
spheres, and, 'as a consequence, the paralysis is bilateral. 
There is first the formation of a single membrane which is 
of a reticular structure, and owing to its great vascularity, for 
it is very highly organized, tlie vessels are easily ruptured ; 
another haemorrhage takes place, and another membrane is 
thus formed, and this process gradually goes on until twenty 
or more of these layers have become organized, and these dif- 
ferent lamellae thus constitute a sac into which blood may be 
poured, which, pressing upon the brain, and constantly in- 
creasing in size from subsequent haemorrhages, give rise to 
well-marked head-symptoms, and gradually increasing paraly- 
sis. It is impossible to diagnosticate the affection with cer- 
tainty during life, as it is so generally associated with other 
cerebral diseases that its symptoms are more or less obscured ; 
nevertheless, by the process of exclusion, we may form a 
diagnosis which ^ jpost-mortem examination may subsequently 
verify. 



126 CLINICAL LECTURES. 

Case IY. Hcematoma of the Dura Mater. — '' Captain C, 
aged forty-five, married, and father of six children, a native 
of Massachusetts, has ever since his youth followed the sea 
for a livelihood. Endowed with a good constitution, and 
temperate in all his habits, he has been quite free from dis- 
ease. When twenty-five years of age, however, he had an 
attack of intermittent fever, from which he speedily recovered, 
and about twelve years ago he had pleurisy, which was brought 
on by exposure. He has no hereditary predisposition to dis- 
eases of the nervous system, nor has he ever had syphilis, 
rheumatism, or any other affections excepting such as were the 
result of traumatic causes. His father lived to the good old 
age of ninety-seven, and his mother died of puerperal fever 
when thirty-five years old. One of his children is at present 
suff*ering from chorea. Some seventeen years ago, in a severe 
gale at sea, he went aloft to cut away some spars which were 
hanging by the rigging, when he was thrown violently into 
the top, striking on his head. Pie was immediately taken 
down in an unconscious condition, in which he remained for 
some time, and when he regained his senses he found that his 
ship had been abandoned, and that he was on board of another 
vessel. On examination it was found that he was not only 
suffering from concussion of the brain, but that he had also 
received severe wounds of the scalp, together with a very bad 
injury of the right leg. After the effects of the concussion of 
the brain had disappeared, he was imable to walk, on account 
of the injury to his leg, from which he has never entirely re- 
covered, and even at the present time he is somewhat lame. 
Subsequently to this accident no head-symptoms were devel- 
oped, and witli the exception of his lameness he was quite 
himself again. He enjoyed excellent health until 

February, 1870. — At this time he was at Darien, Georgia, 
when one evening while returning to his vessel he was as- 
saulted and severely beaten by sonie negroes, who left him in 
an insensible condition. In this state he was found, with 
severe scalp-wounds on the right side of his head, and more or 
less contusion on the left. There was also haemorrhage from 
the right ear, which continued for several days. He was re- 
moved to his vessel, and on the third day became delirious, 



HEMATOMA OF THE DUEA MATEE. 127 

and remained so for a week. On the tentli day lie became 
rational, and on the twelfth he was up and about, attending to 
his duties. 

At this period his friends noticed that his speech was 
more or less affected, and he was aware of a general paresis of 
his upper and lower extremities. He was raore or less deaf 
in both ears, his memory was impaired, and his ideas were 
somewhat confused. There was no facial paralysis, and no 
difficulty of sight. He now gradually improved from day to 
day, and his symptoms were slowly disappearing, when in 
August, 1870, he commenced to suffer from vertigo, whicli 
went on increasing in severity until it became so severe that 
he was unable to arise from the recumbent position, or turn 
over in bed, without augmenting it. He also had a dull, cir- 
cumscribed headache, was stupid, and had a tendency to go to 
sleep at any time. The vertigo was more marked in the morn- 
ino; than in the evenino^. There was no nausea or vomiting. 
Such was the history of this patient up to the time he was ad- 
mitted to the N^ew York State Hospital for Diseases of the 
Nervous System, when his condition was as follows : 

" There is a general paresis of both sides of the body, with a 
marked feeling of weakness in the knees. Tactile sensibility 
is greatly diminished everywhere, excepting in the integument 
of the head. There is a want of coordination in the muscles 
of the tongue, as evinced by the patient's stammering. The 
tongue does not deviate, nor is it restricted in its movements. 
There is no paralysis of the face. His hearing is now very 
good. His pupils are natural and equal on the two sides. 
His memory is little if any affected, and there is no noticeable 
confusion of ideas. His eye-sight is unimpaired. He still has 
severe vertigo, with a tendency to drowsiness, and a constant, 
dull, circum.scribed pain in the head. He is cachectic and 
ansemic. There is no disease of the heart, and the lungs are 
perfectly healthy. The tympanum on the right side is not 
ruptured. Tlie bladder and rectum are normal, and the urine 
is natural. The ophthalmoscope reveals an anaemic condition 
of the retina, the choroid is pale, and the retinal vessels are 
small, straight, and diminished in number." 

This case illustrates so well the symptoms that have been 



128 CLINICAL LECTUEES. 

observed in hsematoma of the dura mater, that, if this man 
should die, I should not be at all surprised to find, upon "post 
mortem examination, the lesions which characterize this affec- 
tion, the pathology of which I have already briefly described 
to you. From the history of the case we learn that this man 
received a fracture of the base of the skull, which was the 
result of traumatic causes, and that this was accompanied by 
meningeal hsemorrhage. I think that we can in no other way 
explain the haemorrhage which took place from this man's ear 
for several days, except by attributing it to fracture of the pe- 
trous portion of the temporal bone, which you are aware gen- 
erally suffers in injuries involving the base of the brain. Then 
you will remember that Captain C. became delirious on the third 
day after the accident, which shows that he was suffering from 
inflammation of the brain, which terminated in the course of a 
week in resolution, for, when inflammation of the brain takes 
place, it either causes death by its extension from the site of 
the lesion to other parts of the brain, or it goes on to the for- 
mation of an abscess, or it ends as it has done in the present 
instance. The symptoms after this attack were those which 
we should expect to find in a person who had had an ex- 
travasation of blood at the base of the brain, and, as this 
was absorbed, these manifestations gradually disappeared. 
Then he began to suffer from vertigo, a dull, circumscribed 
pain in the head, and stupor. These phenomena were un- 
doubtedly due to a chronic inflammation which had been 
taking place in the brain for some time. In hsematoma 
of the dura mater we also have the power of motion di- 
minished on both sides of the 'body, but never to a very 
great degree, and this was the case with Captain C, as 
you will observe that he walks very well, although he says he 
is weak in his lower extremities aud particularly in his knees ; 
and, when I ask him to grasp the dynamometer, you notice 
that he does not turn the index as far as a man who has the 
normal strength in his hands should do. When he speaks you 
will observe that there is a hesitation in his articulation, which 
is not due to paralysis of the tongue, for he is able to move this 
organ with facility in all possible directions, but is dependent 
upon a want of coordination in the lingual muscles. There are 



H.EMATOMA OF THE DUE A MATEE. 129 

also present at this time vertigo, circumscribed pain in tlie 
head, and a tendency to drowsiness, wliich shows that the dis- 
ease is still active. Jaccond has called attention to certain 
phenomena in this disease which he believes are sufficient to 
indicate its presence. Among the most prominent of these 
are the absence of fever, the contraction of the pupils, slow- 
ness and irregularity of the pulse, the severe and constant 
headache, and the increasing tendency to stupor, conjoined 
with the negative facts that there are no facial paralysis, no 
vomiting, and no general convulsions. These phenomena are 
all well illustrated in the patient before you, with the excep- 
tion of the contraction of the pupils, as I find upon examina- 
tion that they are about natural as regards size, and the slow- 
ness and irregularity of the pulse, which do not exist at the 
present time in Captain C, whose pulse is rather accelerated 
and weak. From all of which considerations I am inclined to 
the opinion that this man is suffering from haematoma of the 
dura mater. You know that this disease is found most com- 
monly in children and very old persons, and that it may be 
induced by injuries of the skull, the excessive use of alcohol, 
and fevers, and consequently it may occur at any age of life. 
The prognosis is unfavorable, the patient passing into a state 
of coma, which soon ends in death. 

The treatment merely consists in palliative measures, as 
nothing can be done to cure this affection. 

[XoTE. — This patient was treated by means of the internal 
administration of a sixteenth of a grain of the bichloride of 
mercury, and ten grains of the iodide of potassium, in the com- 
pound tincture of cinchona, three times a day, without any 
amelioration of his symptoms ; and, the vertigo and pain in the 
head, after this remedy had been tried two months, becoming 
more severe, a seton was passed deeply through the nape of 
the neck, from which he for a time experienced some relief, 
and the mercury and potassium were discontinued. But in a 
short period he felt as bad as ever, and another seton was then 
inserted into the nape of the neck, and the primary galvanic 
current was passed through the brain three times a week, one 
pole being placed on each mastoid process, and then one pole 



130 cli:n^ical lectuees. 

on the forehead, and the other on the nape of the neck. After 
tlie lapse of a month he became discouraged, and was dis- 
charged, his disease having undoubtedly increased while under 
observation.— T. M. B. C] 

You remember that I have already lectured to jon upon 
the subject of cerebral thrombosis, and that I showed you at 
a former clinic a good example of this disease in the patient 
whom I have since brought before you several times. 

To-day I present to your notice another case, which I am 
disposed to consider one of cerebral thrombosis, and which is 
all the more instructive inasmuch as it is accompanied by cross- 
paralysis, a symptom which I have fully considered in rela- 
tion with cerebral hsemorrhage. Another point of interest in 
this connection is the absence of aphasia, either amnesic or 
ataxic, which we should naturally expect to find when the 
lesion is situated upon the left side of the brain ; and yet, from 
the very fact of there being no loss of the memory of words and 
no difficulty in coordinating the muscles concerned in speech, 
we are able to say that that part of the brain which is sup- 
plied by the left middle cerebral artery is not involved. Be- 
fore proceeding further, I will call your attention to the his- 
tory of the following case : 

Cerebral Thrombosis^ with Cross- Paralysis and Might 
Hemiplegia. — C. B., aged thirty-five, was born in Ireland, is 
single, and a domestic by occupation. She has never had syph- 
ilis, nor is she predisposed to diseases of the nervous system 
by any hereditary influence, so far as she is aware. Her 
father died of fever, and her mother succumbed to old age. 
She is temperate in her habits, and had always been a per- 
fectly healthy woman all her life until two years ago, when she 
was attacked with acute articular rheumatism, which confined 
her to her bed for a period of about seven weeks. Her heart 
.was not examined either before or during her sickness. Soon 
after this she was up and about, attending to her regular duties, 
and in the course of a few weeks felt as well as ever. At 
times ever since this attack she has suffered more or less se- 
verely from rheumatic pains in different parts of her body, 
but they would only last a short time, and generally followed 



CEREBEAL THROMBOSIS. 131 

exposure to wet and cold to wliicli lier domestic duties neces. 
sarilj subjected her. She attributed lier acute articular rheu- 
matism to this exposure, and no doubt it was the exciting cause. 
About six months ago she went upon the roof of the house 
for the purpose of taking down her washing, and while there 
she ran against a line and severely contused her right upper 
eyelid, causing eversion of it, besides otherwise injuring the 
eye itself. There soon followed a small ulcer upon the cornea 
which is now healed. There has also been a constant dis- 
charge of pus from a fistula of that eyelid, the external ori- 
fice of which is situated just above the inner margin of the 
right eye, and this at present is not closed. Her eyesight 
was always somewhat impaired, but not very materially, and 
it was in executing movements which required the fine ad- 
justment of the eye or its full power, such as threading a nee- 
dle and the like, that caused her to notice any defect in vision. 
The lid has been strapped dov/n, and the eye covered with a 
bandage. 

About a month ago, wdiile at work wringing out clothes 
and exerting much strength, the right arm and leg became 
numb, and lost power, but not sufficient to cause her to de- 
sist from her labor ; nevertheless, it was with great efifort that 
she managed to finish her washing. At the time of the at- 
tack she had no head -symptoms whatever, such as vertigo, 
temporary loss of consciousness, or confusion of ideas. She 
did not notice any strabismus, or other trouble with her 
eyes excepting that already mentioned, nor was she aware 
of any impairment of the muscles of the tongue or of the 
face, although they undoubtedly were present at this pe- 
riod ; nor was she conscious that her face was paralyzed even 
when admitted. Soon after the attack the numbness and 
paralysis were at their acme, and instead of increasing they 
iaimediately began to improve; at least this is true of the 
motility of the right side, and up to the present date this 
has been progressive. Six months ago menstruation ceased, 
and at the time of what ought to have been her regular month- 
ly period she had, instead of her normal catamenia, a violent 
headache, which was not confined to one spot, but was gener- 
ally difi'used over the head, and which usually lasted several 



132 CLINICAL LECTURES. 

hours, and was so severe that she was obliged to lie down and 
keep perfectly quiet until it passed off. 

The patient was admitted to the outdoor department of 
the New York State Hospital for Diseases of the E^ervous 
System, December 16, 1870, when the following points of in- 
terest were observed : 

" The power in the right upper extremity is diminished, as 
measured by the dynamometer, 10°, and this was a minimum 
measurement of the deficient muscular force, as she is natural- 
ly right-handed. The tactile sensibility is slightly diminished 
in the right arm as compared with the left. The lower .ex- 
tremities appear to be normal as regards both motility and 
tactile sensibility, as there is no difference that can be appre- 
ciated between the two sides. The left side of the face is 
jDaralyzed, and drawn to the right. The tongue is drawn to 
the right side to a very great degree, although contrary to the 
general rule, and this is not apparent on account of the oral 
orifice being drawn in that direction, but real. The muscles 
of the face on the left side are flattened, although the naso- 
labial fissure is well preserved ; yet, if the patient be made to 
laugh or to frown, the immobility of the muscles on the left 
side, as compared with those of the right, is plainly visible. 
There is no difiiculty in closing the left eye. The tactile sen- 
sibility is diminished on the right side of the face, while it is 
normal on the left. The sensibility to the taste of sapid sub- 
stances is almost lost, if not completely so, on the right side of 
the tongue, while it is natural on the left, and the tactile sen- 
sibility is also impaired in the right half of that organ. The 
sensibility to the electric current is diminished on the right 
side of the face, and the right side of the tongue and the buc- 
cal cavity. The angle of the mouth is drawn to the right, and 
the muscles on this side respond much more readily to a strong 
induced current than those on the left. The forehead on the 
Jeft side is quite smooth, while on the right it is much 
wrinkled. There is no difiiculty experienced in chewing on 
either side, and the food does not lodge in the cavity of the 
left cheek sufficiently to cause her any inconvenience. There 
are a thickness of speech, and a change in her voice, which de- 
pend upon paralysis of different muscles, namely, those of tlie 



CEEEBEAL THROMBOSIS. 183 

lips, the tongue, and tlie left cheek. The pupils are equal on 
the two sides, and about normal in size. Tliere is no ptosis 
nor strabismus. There is no loss of the memory of words, 
no difficulty in speech at all, excepting that which is caused 
by paralysis. There is no trouble with the rectum nor the 
bladder. The heart and lungs were carefully examined, and 
were found to be perfectly healthy. On tickling the right 
hand and foot, or irritating them in any way, the reflex facul- 
ty is fonnd to be very much impaired. The paralysis of the 
face has diminished, since the patient came nnder observation, 
but yet it is at present quite well marked, and so is the devia- 
tion of the tongue. Even now she cannot w^histle, yet she can 
expectorate, although not very easily. When she blows to 
extend her cheeks by closing her mouth, the right cheek is the 
more extended or inflated, and the angle of the mouth on that 
side is the more firm. She has improved very greatly with- 
in the past two weeks, and as a consequence her symptoms 
are correspondingly modified. Shortly after her attack, her 
attention was drawn to tingling sensations in the fingers and 
toes on the affected side ; these would come and go, and they 
have for no great length of time persistently remained. Ex- 
amination of the fistula of the right upper eyelid shows that 
it terminates in a bony canal which has been formed in the 
orbital plate of the frontal bone." 

It would appear from the history of this case as though a 
very short period had elapsed from the commencement of the 
disease of this patient until it was fully formed ; but when we 
come to consider that her face was greatly paralyzed, and her 
speech was much affected from the implication of the genio- 
hyo-glossus muscle on the right side which caused the point of 
the tongue to be carried in that direction, and that even when 
admitted she did not know that these organs were involved, 
it is hardly possible to believe that the attack took place in so 
short a period of time as the patient has stated. 

You remember that there were no head-symptoms what- 
ever excepting a severe headache, which made its appearance 
some six months prior to the loss of motility and sensibility, 
and which from its general characteristics was not the head- 
aclie of cerebral thrombosis, which is rarely diffused over the 



134 ' CLINICAL LECTUEES. 

whole head, but is rather limited to a situation which is in 
close relation to the seat of the disease. Then, again, it is 
rarelj verj severe, and is noted more for its persistency than 
its severity. In all of which respects it differs so markedly 
from that which we now find in this patient, that we are able to 
attribute it to the disordered menstrual function rather than 
to cerebral thrombosis. 

Although we have in this case the history of acute ar- 
ticular rheumatism with subsequent subacute attacks, yet, 
when we come to examine the heart, we find no functional 
or organic disease. Then, again, the attack did not take 
place instantly, as it always does in embolism ; the paralysis 
is also on the right side of the body, and the lesion is situ- 
ated upon the left side of the brain ; yet there is no loss of 
the faculty of language, no mental disturbance, and no loss 
of consciousness — all of which considerations induce me to be- 
lieve that this is a case of cerebral thrombosis. You are 
undoubtedly aware of the fact that obliteration of a cerebral 
artery does not always give rise to notable symptoms. In 
order that these should be manifested, it is necessary that the 
morbid process should take place in a vessel which has few 
and small collateral branches ; as, for example, if a thrombus 
should be so situated as to occlude the basilar artery, so that 
one or more of its transverse branches were involved, thus 
cutting off the supply of blood to the pons Varolii, the re- 
sult would be first an anaemic condition of that region, which 
might subsequently end in softening. If, however, a thrombus 
should obstruct the internal carotid, the brain circulation would 
not be markedly affected, for the blood would be sent through 
the vertebrals to the basilar, and thence through the circle of 
Willis, so as to prevent that part of the brain from suffering 
from a want of proper nutrition. Again, if the basilar artery 
should be obstructed between a pair of transverse branches, 
the circulation would still be maintained by means of the col- 
lateral branches derived from the carotids and the vertebrals. 
You are perhaps not aware of the fact that, when an artery in 
the brain is closed by a thrombus, or an embolus, the col- 
lateral branches are never entirely able to compensate for the 
loss of the primary vessel. 



POSTERIOR SPINAL SCLEROSIS. 185 

Xow, what is the condition in this case, and what part of 
the brain is involved ? Yon observe that the patient is par- 
alyzed npon the left side of her face, while her body is par- 
alyzed upon the right side, w^hich in my opinion indicates a 
lesion of the pons Varolii, whicli has involved the facial 
nerve below its point of decussation, which always produces 
paralysis of the face on the corresponding side, and loss of 
.sensation and of motion on the opposite side. Another rea- 
son why I regard the pons as the part involved in the patient 
before us is the loss of the reflex excitability to wdiich I have 
especially referred in the case of John Fetter, and which 
you remember is particularly mentioned in the history of that 
case. 



LECTUEE X. 

POSTERIOR SPINAL SCLEROSIS. ' 

Case. " William Casey, aged sixty years, was born in 
Ireland, and has been sick ten or twelve years. He was first 
attacked with j)ain, he says, ' in the spine of his back.' At 
the present time he has shooting pains down the legs, which 
are neuralgic and electric-like in character. These pains 
sometimes keep him awake at night, and move from one leg 
to the other. He has now a slight cloud at times over one 
eye, but there is no dizziness, and no trouble with his speech, 
nor are there any twitchings of the legs. He has, however, 
occasional palpitation of the heart ; he never has suffered from 
vomiting, but has experienced a curious feeling in his hands 
for the last month or so ; at the present time he can pick up a 
pin, but he could do it better a month ago than now, and his 
fingers are also beginning to get a little numb. He can feel 
the ground w^hen he stands or walks, and has no burning sensa- 
tion in the soles of his feet, yet he cannot place his foot where 
he wishes, and he cannot go easily up stairs or down ; if he at- 
tempts to walk in the dark, he falls down ; and walking on the 
ice, or on any smooth surface, is attended with great difficulty. 
When he shuts his eyes he staggers very much ; he puts his 



136 cli:n"ical lt:ctures. 

foot down with two movements ; the heel strikes first, and 
the sole of the foot follows at an appreciable interval. He 
cannot walk with his eyes shut, and, when he places his foot 
upon a chair, it is done with a jerking motion. lie passes his 
water freely, although he suffers from some slight irritability of 
the bladder, which is not uncommon in men of his age, and is 
not very important in this connection. There is undoubt- 
edly a little weakness of the bladder, and perhaps a little 
relaxation of the sphincter, but these conditions are not very 
well marked. He is inclined to be costive. Tliese are the 
principal features of the case." 

Here is a man who staggers when he walks, moves a little 
from side to side ; or, in other words, has what is called the 
titubating gait, which is one of the characteristics of the dis- 
ease now under consideration. He has a double motion in 
the action of the foot. This is also characteristic. His walk 
is distinguished by two distinct movements of the foot. He 
cannot walk with his eyes shut, which indicates that he has 
lost knowledge of exactly where his feet are, and he is there- 
lore unable to advance. He cannot stand alone with his eyes 
shut, for the same reason. The sensibility of the soles of his 
feet is lost, which prevents his knowledge of their exact loca- 
tion, and with this he has lost another sense, viz., the muscular 
sense. In other words, he has lost the appreciation of the state 
of contractility these muscles are undergoing at the time he 
is using them ; consequently, in the efforts of standing and 
movement, which require a certain degree of coordination, 
the muscular contractility necessary to maintain an erect posi- 
tion or cause motion is not appreciated, and therefore he falls 
down. If he can see his feet, he is able to walk very well, but 
even then he does it by spreading his limbs and widening the 
base upon which he stands. He is also forced to use a 
cane when he walks and to keep his eyes a few feet in ad- 
vance of his steps. Sometimes these patients are obliged to 
stoop a little, that they may look out their footsteps as it were. 
This patient without doubt has ansethesia. We can say very 
definitely that he has lost sensitiveness of the soles of his feet. 
There is some loss of sensibility in the hands, in the ends of 
the fingers ; and he has lost the ability to perform nice move- 



POSTEEIOK SPI:N^AL SCLEROSIS. 137. 

meuts witli them. That precision which is natural, is to a 
certain extent gone, and he cannot do those delicate things, 
such as picking up a pin, etc., as well as he could a month 
ago. In the first place, he had no trouble with his arms at 
all. There are no head-symptoms of any moment. No gas- 
tric disturbance, and very little of the intestinal canal. What 
is the diagnosis ? 

SCLEKOSIS OF THE POSTERIOR COLUMNS OF THE SPINAL CORD. 

We have a pretty clear account of all the symptoms which 
are peculiar in that condition, especially when it begins in the 
lower portion of the cord, and has not advanced any further 
than this case has. It is not one of those instances in which 
the trouble begins in the head and goes downward, and is 
characterized by head-symptoms at first, such as vertigo, and 
disturbances of vision. The disease in this case is not about 
the medulla oblongata, because he has no gastric symptoms, 
and no disturbance of the respiratory processes. It simply 
involves the lower extremities. It is, as usually is the case, 
extending, and perhaps has been for a long time. It some- 
times takes a long time to reach the medulla, but that the roots 
of the median nerves are now being involved in this case is 
evident from the fact that the want of coordination begins to 
show itself in the movements of the upper extremities. 

The progress of the disease is slow in this instance, for 
it has taken ten years to get to this point. Sometimes the 
disease advances rapidly, but it is usually slow. It is rarely 
the case that the termination takes place within six or eight 
years, but occasionally it does. A gentleman from Cleve- 
land, Ohio, consulted me for treatment of his case, which was 
essentially the same disease we are now considering ; he had 
been treated for dyspepsia, and neuralgia. I may remark, in 
this connection, that neuralgic pains are very characteristic of 
this affection, and the existence of these neuralgic pains is the 
pathognomonic symptom, if any, aside from the lack of co- 
ordination. This gentleman had been treated finally for soften- 
ing of the brain. But his was a case of sclerosis, beginning 
at the origin of the third pair of nerves at the base of the 
brain, and descending. Such cases are usually rapid, and do 
not in general extend beyond a couple of years. 



138 CLINICAL LECTUEES. 

This man can scarcely be called paralyzed. He may 
have lost strength ; he probably can perform a pretty fair 
amonnt of labor in a short time, but very soon gets tired. 
He cannot walk very far. If, however, yon direct hioi to 
pnsh, he can do that tolerably well, perhaps with almost as 
mncli force as ever. It is usually the case, in the first stages 
of the disease, that when a patient presses against a dyn- 
amometer, he can exert almost as much strength as ever, but 
he cannot continue it for any lengih of time. A continued 
exertion soon tires him out ; he finds himself more easily fa- 
tigued this year than last. (At this point the patient had 
a coughing- spell of a somewhat spasmodic character.) When 
the patient coughs, he coughs in the manner just s-een^ and he 
without doubt has some trouble about his swallowing. It 
sometimes happens that these symptoms occur. There is a 
little want of coordination in the muscles of deglutition, and 
articles of food stick in the throat, and may go down into 
the trachea and choke the patient. I have seen many cases of 
this disease in which that symptom was a prominent feature. 

There are some other symptoms whicli usually are pres- 
ent, but which are not absolutely essential. We usually 
possess a pretty clear, knowledge of the situation of any por- 
tion of our bodies, as a spot upon the forehead, the centre of an 
eyelid, the centre of the upper lip, or tip of the nose, and as 
a rule we liave no difficulty, when we close our eyes, in placing 
our fingers exactly upon the designated spot. "When the up- 
per extremities are involved, the patient cannot perform this 
act with precision. (Trial was made with this man, his eyes 
being closed, and he invariably struck his lip just beneath his 
nose, instead of placing his finger upon the tip.) This feature 
is constantly present when the upper extremities are involved 
by the disease. These patients are also apt to lose their ap- 
preciation of weight. 

This is^ tested by an instrument called the barosthesiometer, 
and in this case it is found that the appreciation is but 
little if any lessened, which shows that the upper extremities 
are not very much affected. In extreme cases the loss of ap- 
preciation is so great that the difference between one pound 
and one hundred pounds cannot be told. I myself have seen 
cases almost as bad as that. 



POSTEKIOE SPmAL SCLEEOSIS. 139 

An examination with the sesthesiometer will show that 
tliis man has lost sensihilitj in the legs ; that he is not able to 
distinguish impressions with as much accuracy as formerly. 
Sometimes the ability to transmit impressions from the brain 
through the nerves is very materially interfered with. To 
illustrate : I had one patient who, when pricked in the leg, 
could not realize the fact until several minutes had elapsed after 
receiving the puncture. There was therefore retardation in the 
rapidity with which impressions are usually conveyed to the 
brain ; the nerve losing, to some extent, its conducting power. 

Causes. — This patient does not know what produced his 
disease, unless it was goiug down into a damp cellar. He was 
intemperate at the time he was taken with the disease. He 
had been, in his earlier days, fond of three things : a dog, a 
handsome woman, and plenty of good whiskey. This is a very 
good formula for the provocation of the affection from which 
he is now suffering. Sometimes it is produced by cold ; some- 
times by habits of intoxication ; sometimes, perhaps, by vene- 
real excess, but this latter is a difficult matter to determine, 
because it is almost impossible to say what excess is in the 
matter of sexual intercourse. It probably does, however, oc- 
casionally, lead to the production of posterior spinal sclerosis. 

Treatment. — Treatment very rarely does any good. What 
we do we are obliged to do empirically. We know little in 
regard to the nature or manner in which our remedies act. 
The treatment is simply the result of experience. I gener- 
ally begin with the administration of ergot, for the reason that 
the disease in the first instance is usually congestion, and ergot 
is therefore indicated. This remedy sometimes produces very 
decided improvement from the first. . I generally give it for 
about a month, and follow it with the nitrate of silver, and 
frequently continue this with the lacto-phosphate of lime, 
which is a tonic to the nervous system. 

The nitrate of silver is to be given in half-grain pills, three 
times a day for twenty-five days in each month ; you give this 
interval of five days in each thirty to prevent the discolora- 
tion of the skin. With this interval of five days in each 
month, it may be continued for a year or more without color- 
ing the skin. Whether this is the cause of the exemption or 



140 CLINICAL LECTURES. 

not I do not know. The lacto-]3lio3pliate of lime in syrup 
may be given in dessert-spoonful doses after meals and the 
silver pills before meals. 

In general the treatment fails very much more frequently 
than it succeeds. I have never cured more than five cases out 
of a hundred. Ten years ago we did not cure any cases of epi- 
lepsy, but now we cure twenty out of every hundred. So it 
is something to be able to cure live out of every hundred suf- 
fering from locomotor atax3^ 

In connection with these measures I usually employ the 
primary galvanic current, applied along each side of the 
spinous processes of the vertebral column, by placing one pole 
of the battery upon the backbone above, and stroking the 
back with the other along the line indicated, every alternate 
day for a period of several months. If you continue it but 
for a single month, it will do no good. At the same time I 
use the induced current to the legs simply for the purpose of 
keeping the muscles in a state of activity. The induction-cur- 
rent keeps them in a healthy condition, and acts upon the 
muscles locally. This treatment gives the best results of any 
I have ever adopted. As a rule, the patients will resist all 
treatment ; nsually grow ^worse and die. Occasionally they 
do not die, but remain as this man is now for years. 

I had a patient from Boston wlio continued in this fixed po- 
sition, as regards the progress of the disease, for twelve years. 
He would occasionally come to see if any thing new had been 
discovered in the line of treatment, and in this way I had his 
ease under observation. 

The disease is not very often met with in women. This is 
a curious circumstance, and I do not know why it is. We 
saw last year at this clinic only two cases occurring in females. 
It is almost peculiar to the male sex, but occasionally females 
become affected. 

One great trouble in the treatment of these cases is, that 
the patients will not continue it long enough. It is only per- 
sons who have a marked interest in getting well, that get 
well. Nothino; can be done in the course of a week or month. 
It requires months and years to produce a cure, if at all. It 
is characteristic of the disease to exhibit remissions. Some 



POSTEEIOE SPIIS^AL SCLEEOSIS. 141 

cases will improve without any treatment ; so, while you are 
employing your remedial measures, and your patients are ap- 
parently getting well, you must be upon your guard in re- 
spect to your prognosis, for when you least expect it the patient 
may very rapidly drop back to his former bad condition. 



LECTrEE XI. 

POSTEEIOE SPIRAL SCLEEOSIS. ABOETED EPILEPSY. ATHETOSIS. 

Case. Posieinor Sjpinal Sclerosis. — A. W., forty -two years 
of age, married, and a tailor by occupation. About two years 
ago he began to be affected with, sharp, electric-like pains in 
the legs, which went on gradually increasing in severity. He 
soon began to lose the power of coordinating his legs, but he 
has never lost his ability to walk in the light, although he 
cannot walk in the dark, or stand up with his eyes closed. 
He stands with his feet very far apart, in order to increase his 
breadth of base, and he places them down with the character- 
istic double movements. 

There are one or two peculiar features in this case. He 
has no difficulty with his bladder. This is somewhat unusual 
in a case as far advanced as this. The disease which affects 
the cord usually exists above the point of origin of the vesical 
nerves, and there is almost invariably some trouble with the 
bladder, either of the sphincter or of the viscus itself. It is 
important to recollect, therefore, that there are cases of this 
disease in which the bladder is not involved. 

The patient has never experienced that very common sen- 
sation of tightness about some part of the body, such as would 
be produced by a cord. 

There is no trouble about his head. It is not one of those 
cases in which the trouble began in the optic nerve, and de- 
scending attacked the cord afterward, for he has had no ver- 
tigo, nor disturbance of vision until lately, and now he has 
some trouble in the left eye. He cannot fix it in one position 
unless that position is straight ahead ; and he can hold his eye 
still then, because all the muscles of the eyeball balance 



Ii2 CLINICAL LECTURES. 

themselves exactly, and no particular muscle is placed in a 
state of contraction. In other words, he has slight nystagmus, 
which is indicative of some trouble about the base of the brain. 

He has probably two centres of disease ; one in the lower 
portion of the spinal cord, and one at the base of the brain. 
He has had this disease only two years, which is a very short 
time to bring him to the state he is now in, as it usually takes 
very much more time than that. Tip to May last he could 
walk quite well, but has grown rapidly worse since. He 
can work at his trade now, and has no trouble with his arms 
as yet ; for he experiences no trouble in handling or thread- 
ing his needle. There is as yet no effect upon coordination, 
but before very long he will not be able to do these things, un- 
less there is an arrest of the disease at the upper focus, and 
then there will be slight twitches in picking up things, such 
as needles, pins, etc. 

This man has always been quite regular im his habits, and 
has probably not used liquor to much excess, and he has never 
received any injury upon the back. 

The first intimation he had, was the turning of the foot 
under. The pain, however, existed before that for some time. 

This is a very rapid case, if it be true that it commenced 
two years ago with the first sufferings from pain. He has 
more or less pain now, generally in the legs, but never in one 
place constantly ; sometimes in one leg, sometimes in the 
other, but mostly in the day, tliough sometimes in the night- 
time. These cases usually suffer most pain at night-time. 
He never gets cramps in the legs, and never feels as though 
cushions were under his feet when walking. He is obliged^ 
however, to keep his eyes upon the ground a few feet in ad- 
vance of him, and requires the assistance of the eyesight to get 
along. He can push probably as strong as ever, as you now 
see by the resistance he makes. There is no paralysis, there- 
fore, and the defect is mainly one of incoordination, the paraly- 
sis not having yet begun. With all this manifest strength 
in pushing, he can keep it up but for a short time, and the 
legs can be tired out quite rapidly, yet his strength is really 
remarkable, considering his inability to walk ; you rarely see 
siich a case. This patient probably cannot walk a quarter of 



ABOETED EPILEPSY. 143 

a mile ^vithout being exhausted. lie never had palpitation 
of the heart. He is, and has been, troubled with vomiting to 
a considerable degree. Frequently, these patients are treated 
for dyspepsia, when the real trouble is locomotor ataxia. 
These dyspeptic symptoms are generally among the first, and 
disappear after a while. He will probably have, very soon, 
vertigo and double vision, which wdll last for a month or two, 
perhaps more, and then these symptoms will disappear, and 
he will lose power in the arms. 

If possible, we must arrest that development of symptoms. 
This man should take the tincture or fluid extract of ergot in 
large doses. I have seen the initial symptoms rapidly cut 
short upon the administration of ergot in large doses ; give it 
in teaspoonful doses of the extract, or two teaspoonful doses of 
the ordinary tincture. Some patients will not tolerate ergot 
in any doses, but such cases are not very common; after 
taking it for a month, place him upon the persistent use of 
nitrate of silver, apply the primary current to the brain and 
upper part of the spinal cord ; there is not much to be done for 
the legs, yet these measures, applied to the upper part of the 
cord, will act favorably for them. Sometimes treatment makes 
these €ases worse, sometimes no benefit at all is derived, and 
sometimes the measures recommended are very beneficial. 

This is a very interesting case. It is mainly so because of 
the immense muscular powder which the patient has in com- 
parison to his bad walk. His gait would indicate that he had 
lost strength and was paralyzed, but it is entirely the result of 
the inability to coordinate. 

Case. Aborted Epilepsy. — A colored girl, aged eighteen. 
The mother says, " She does not act as though she was in her 
right mind," that she laughs, and at times appears silly. She 
has never attempted to hurt herself or anybody else. She has 
fits at the present time, and loses consciousness. These attacks 
first made their appearance when she was about eight years of 
age, and, after lasting for a short period, disappeared; and 
since, she has been quite free from them, excepting on one occa- 
sion, for the last ten years. About the 6th of last September 
they again returned, and she had three the first dav, two the 



144 CLINICAL LECTUEES. 

next, and then she liad none for a week ; then she had another 
fit, and was again fi'ee for another week, and so thej have 
continued down to the present time, taking place about once a 
week. Her mother observed that the attack was sometimes 
induced by the contact of her hand against the shoulder when 
striving to arouse her in the morning. Her com-ses came on 
at twelve years of age. 

This is a case characterized by tolerably well-marked epi- 
leptic paroxysms. She does not bite her tongue, and only 
about one-third of the cases do, nor does she froth at the mouth. 
In some text-books you will see it laid down that frothing at 
the mouth is one of the pathognomonic symptoms of epi- 
lepsy ; but it is present in only about one-half of the cases, 
even when they have the grand-mal, and with the fetit-mal 
of course they have no frothing at the mouth. This girl 
would probably have been cured of these fits, had she been 
treated when first attacked, at eight years of age. In such 
cases there is some hope that, when puberty arrives, the epi- 
lepsy will cease of itself. Probably the patient also has 
epileptic mania, but I like the term aborted attacks better. 
When these paroxysms are on, she is a little spiteful to her 
brothers, but nothing violent. There are various kinds of at- 
tacks. Some patients are seized suddenly, and will jump up, 
run about the room, and perhaps talk some gibberish ; or get 
np on a chair, and whirl around, etc., without knowing what 
they have done. In other cases, we have well-marked signs of 
mania; sometimes of a very mild form, and sometimes of a 
very dangerous form. 

In this case they are mild in character, but during the at- 
tack, however, she knows nothing of her actions. There are 
cases on record of this kind in which the patient has got up in 
the middle of the night and either killed all the family, or 
seized the children and thrown them out of the window, and 
known nothing of what had transpired. It is well to know 
that there is something of this kind. The lawyers have got to 
be aware of the existence of such a disease, and it becomes of 
importance in a medico-legal point of view. These patients 
have pain in the head, and usually are dizzy at some part of 
the day. The fact of her being seized with an epileptic at- 



ATHETOSIS. 145 

tack wlien touched by her mother simply shows a great ere- 
thism of the nervous system. It is certainly true that epilep- 
tiform paroxysms may be brought on by reflex action, but 
there is no great collection of facts to prove that true epilep- 
sy is produced in that way. 

The following will be recommended for this patient, accom- 
panied with the request that she return in about three weeks : 

5 . Potasses bromid., § i. " 
Aquae, | iv. M. 

Two teaspoonfuls twice a day. 

Deeember 21^^. — Doses increased to 45 grains, three times 
per day. 

Has had some attacks. If, after taking one teaspoonful and 
a half twice a day of a saturated solution of the bromide (45 
grains), she has an attack, give two teaspoonfuls three times 
a day (60 grains). These fits have ceased since the patient 
has taken 240 grains a day. 

Case. Athetosis. — This woman has been sick for fifteen 
years. What you see now is a jerking of the left arm and 
hand ; this she can sometimxcs control by holding them folded 
under the other arm. The entire side moves in the same 
way. The face jerks when she gets very mucb excited. The 
hand in the morning is cold, and she has occasional pain in 
the head. The muscles are never in repose, not even when 
she is sleeping. 

The woman supposes that the affection came on from a sud- 
den check of perspiration. She says that she went into a cold 
bath while in a state of perspiration, and this jerking of the 
hand and arm commenced immediately afterw? d. 

This is a case of irregular muscular action, which it is diffi- 
cult to place exactly. But I am inclined to the opinion of Dr. 
Cross, that it is a case of what I have described as athetosis. 
It consists of involuntary muscular movements, but different 
from simple flexion and extension. Coordination is gone. 
The movements are pretty much of the same kind, but are 
mor& regular and systematic than those of chorea. They are 
somewhat paroxysmal, being worse at one time than at another. 

This irregular muscular action affects, in this case, mainly, 

10 



146 CLmiCAL LECTURES. 

the fingers, and the foot, and this "vvas characteristic of the 
three cases which I have seen recorded. The first case I ever 
saw or heard of was one which I exhibited in the beginning 
of the session. In that case the irregular muscular action fol- 
lowed upon drinldng sixty glasses of gin in one day. 

Dr. Hubbard, of Ashtabula, Ohio, sent me the history of a 
case similar to it, and these cases were sufficiently isolated to 
warrant me in making them the foundation of a new disease, 
and they form the basis of the article in my treatise on " Dis- 
eases of the Nervous System." JSTothing was seen of it before 
these cases. Dr. Albutt, of Leeds, England, reported another 
case, wdiich he said was similar to those I have mentioned in 
my work. The first two cases were in men, but here is an- 
other case, which seems to be about the same thing, in a 
woman. There is not quite the same extent of movement . as 
was exhibited in one of the cases I have already shown you. 

What the pathological conditions are, is not known. 'No 
2?ost mortems have been made, but there is probably some trou- 
ble about the corpus striatum ; what the nature of the mor- 
bid change is, is not known ; it is pretty much guesswork. 

In the treatment nothing has been permanently beneficial. 
I^one of them recover. In the other two cases, in this coun- 
try, the patients had had epileptic paroxysms at the beginning, 
but this case did not begin with an epileptic paroxysm. All 
that the epileptic paroxysm means is, that there was some 
disturbance of the nervous system in connection Avith this dis- 
ease. Probably some functional derangement at first, which 
has become organic. The use of the primary galvanic current 
usually has some effect in mitigating the spasms. This wom- 
an is receiving this treatment now, and the muscles are very 
much more quiet than formerly. 



PKOGEESSIYE MUSCULAR ATROPHY. 147 



LECTURE XTI. 

PROGRESSIVE MUSCULAR ATROPHY. PROGRESSIVE MUSCULAR 

ATROPHY AJ^D POSTERIOR SPINAL SCLEROSIS. 

Before proceeding to make any remarks upon the subject 
of progressive muscular atroplij, permit me first to read to you 
tke history of the following case ; 

Case. Progressi'ce Muscular AtToj>hy. — " W. E. M., aged 
twenty-five, single, was born in ;N"orth Carolina, and has fol- 
lowed the occupation of a planter all his life. He has always 
been abstemious in his habits, and has never had any dis- 
ease whatever, excepting an occasional attack of acute bron- 
chitis, when exposed to wet and cold, from which he suffered 
c[uite severely at times until he was about fourteen years of 
age, since which period he has been entirely free from these at- 
tacks, 

" In regard to his hereditary predisposition to diseases of 
the nervous system, he gave the following history : His grand- 
mother on his father's side, at the age of sixty-five, first lost 
povv^er in both lower extremities ; after a while the upper limbs 
became more or less involved as the disease extended upward. 
She also at this period began to lose flesh quite rapidly, being 
before this attack quite stout. For ^yq years she was unable 
to use her legs to such an extent as to be able to walk, but 
after tlie lapse of this time she began to improve, and very 
gradually regained strength in her lower extremities, so that 
some years prior to her death she was able to go about very 
well. She lived to the age of eighty-two. 

" Two of his mother's brothers died of consumption before 
they were thirty years old. His father died of erysipelas. Ex- 
cepting his grandmother, we can obtain no other evidence in 
his family of any member having had any disease of the ner- 
vous system. Up to the age of nineteen he had enjoyed as good 
health as the average of mankind, and it was at this period 
(18G6) that he went into the army under the command of Gen- 
eral Lee. It was here, for the first time in his life, that he 
was much exposed to the inclemencies of the weather, and en- 
dured many hardships, yet his health did not seem to be at 



148 CLINICAL LECTURES. 

all impaired. During an engagement in May, 1866, he was 
shot through the left wrist, and both the radius and ulna 
were fractured. Shortly after, while still under treatment for 
this gunshot-wound of the wrist, he was riding on horse- 
back, when his horse fell, throwing him violently against a 
tree, and injuring his left side and he^d. He was unconscious 
for a few moments ; on regaining his senses^ however, he felt 
dizzy and nauseated, but he soon remounted his horse and 
rode back to camp, a distance of half a mile. He now discov- 
ered that he had quite severely injured his broken wrist, and 
as a consequence there followed a copious discharge of pus and 
small spiculge of bone from the wound. 

" In the course of a month he became Terj much depressed 
in spirits, and felt as though lie were about to be afflicted with 
some serious disease. It was at this time that he experienced 
acute electric-like pains darting through the muscles of both 
leo^s ; these were much more severe at nio-ht than during: the 
day. Soon the patient was aware of a slight paresis in the 
lower extremities, an easy susceptibility to fatigue upon taking 
his accustomed exercise ; then he was seized with a constant 
dull, aching pain in the small of the back which he aptly de- 
scribed as the ' backache.' . He now noticed that his ideas were 
confused, that his memory was impaired, that he had vertigo^ 
pain in his head, hallucinations of vision, together with hallu- 
cinations of hearing. Gradually the head-symptoms grew 
worse, and the loss of the power of motion and * the slight 
numbness which the patient had experienced at the commence- 
ment of the disease in the legs, progressively increased in de- 
gree for a period of about three months, at the end of which 
time he found that both upper extremities were decidedly 
involved, for he now was conscious not only of sensations of 
tingling, numbness, and twitchings in the fingers and hands, 
which had been only slightly marked for the past six weeks, 
but he also felt a lack of power in an equal degree in both 
hands as he had in both lower extremities. 

" About the first of August, 1866, his head-symptoms be- 
gan to disappear, and he could walk with very much less ef- 
fort. He had now been under treatment some three months. 
A month later the sharp, electric pains had vanished, and his 



PEOGRESSIYE MUSCULAR ATEOPHY. 149 

head-STinptoms had notably improved, for there were no hallu- 
cinations of sight or hearing, no difficulty in talking, such as 
he had formerly noticed, no headache, no vertigo, no Toss of 
memory, and no confusion of ideas. He was at this time gen- 
erally reduced in flesh, but there was no apparent atrophy of 
the legs present. The backache still persisted, as did also the 
numbness and loss of power in the legs, but the loss of mo- 
tility, together with the abnormal sensations in the upper ex- 
tremities, had entirely disappeared. 

" He now went to work every day and did much hard out- 
door labor, such as cutting wood, lifting heavy timber, carry- 
ing water, etc., which the exigencies of war compelled him to 
do, although quite unfitted for such laborious exercise, never 
having completely recovered. As a consequence of this severe 
exertion in his debilitated condition, in the month of May, 
1867, his head-symptoms returned with increased severity, his 
backache, \^^iieh had been present up to this time, became 
much aggravated, the electric pains recurred with renewed 
violence, the numbness was more marked, and there w^ere su- 
peradded cramps, fibrillary contractions in both hands and 
legs, with twitchings, tinglings, and formications. ISTow the 
loss of motility was quite perceptible, and this increased to 
such a degree that in three weeks the patient was obliged to 
resort to crutches, and six weeks subsequently he was confined 
to his bed, where he remained for a period of four months, un- 
able to move any part of his body, excepting his head. About 
three weeks prior to his confinement to bed, he began to ex- 
perience a constant desire to urinate, and the demand became 
so urgent th-at, if it were not immediately attended to, his water 
dribbled away involuntarily. JSTot only was there a weakness 
of the sphincter of the bladder, but there was a paralysis of 
the muscular walls of that organ, as evinced by the straining of 
the patient in order to empty the bladder. These two condi- 
tions are very commonly met with in diseases of the spinal 
cord. The head-symptoms, which we have already mentioned,, 
went on from bad to worse, and continued for nearly the whole 
time that he kept his bed. He likewise observed tliat his tac- 
tile sensibility was so much impaired that he was unable to 
appreciate with any certainty the sense of touch in his extremi- 



150 CLINICAL LECTURES. 

ties. He first noticed tlie atrophy in his legs in May, 1867, 
and it appeared to him to extend quite rapidly. His bowels 
had been constipated ever since the commencement of this at- 
tack, but he had never had the feeling of constriction like a 
tight band around the waist, which is so frequently a symptom 
of organic disease of the spinal cord. 

"During the month of November, 1867, the tactile sensi- 
bility began gradually to return, and from this time he com- 
nlenced to improve in all respects, so that he was soon able to 
sit up in a chair and give his hands a very little voluntary mo- 
tion. Two months later the abnormal sensations in the head 
and fingers had also disappeared. For three years he could 
not w^alk at all, although the motility in his hands had com- 
pletely returned ; nevertheless the fibrillary contractions, the 
cramps, the feelings of cold, the numbness, and the jerkings, 
still continued in the lower extremities, only they were very 
slightly marked. The atrophy which had at first progressed 
quite rapidly, had, during this period, increased very slowly 
and gradually. In August, 1870, he could walk, with the as- 
sistance of a crutch, but he still had a pain in his back, slight 
numbness, with a sensation of cold, and well-marked atrophy 
in the legs. For a time, then, he had gradually improved in 
walking, but at the date of his admission, February 18, 1871, 
into the ISTew York State Hospital for Diseases of the Nervous 
System, although he could walk two miles on good even groimd 
with the assistance of a crutch, yet he was conscious of the 
fact that, as the atrophy increased, and his symptoms of con- 
gestion of the spinal cord diminished, he constantly grew 
worse. On examination at that time his condition was found 
to be as follow^s : 

'' In the legs the extensors, together with the gastrocnemii 
and solei muscles, were found to have almost entirely disap- 
peared, while tlie atrophy in the thigh was distinctly visible, 
and this loss of power had been directly proportional to the 
extent of the atrophy. The gait of this patient was also high- 
ly characteristic of the disease from which he w^as sufiering. 
In w^alking, he lifted his feet high from the ground, through the 
action of the flexors of the tliigh upon the pelvis, in order to 
clear his toes, which dropped to an extreme degree, and his 



PKOaEESSIYE MUSCULAE ATEOPHY. 151 

knees were in tliis way bent to a greater extent than usual. 
The legs were very mucli reduced in size, and tlie loss of mus- 
cular fibre was quite apparent from tbe greatly-diminished 
electric contractility in these parts. There was no atrophy to 
be discovered at that time in any other part of the body ex- 
cepting the lower extremities, nor did the patient have any 
head-symptoms whatever, nor had he any loss of motility, or 
any abnormal sensations in his upper limbs. His bowels were 
reo'ular, and he had no trouble with his bladder. There was 
no loss of tactile sensibility, nor were there any sensations of 
numbness in the legs. His heart and lungs were in a healthy 
condition. The reflex excitability was diminished in the low- 
er extremities, as was likewise the temperature, and the cap- 
illary circulation was very sluggish, as was demonstrated by 
the decrease of temperature, which was several degrees below 
the normal standard, and the effect of pressure. There were 
no fibrillary contractions present, nor had the patient experi- 
enced any electric-like pains, cramps, jerkings, or other abnor- 
mal sensations, for some time in his legs. The outline of the 
fibula and tibia, together with the knee-joints, were distinctly 
discernible, owing to the destruction of the muscles on the an- 
terior surface of the leg, while the posterior aspect of the calf 
was flattened from a like cause. His backache had completely 
disappeared, but, although he felt well and suffered no pain, he 
appreciated the gradual loss of power in his lower extremities. 
His appetite was good, and his mind was very active. He 
hoped to be cured, as he thought his age 'was greatly in his 
favor. Ophthalmoscopic examination of the eyes disclosed an 
ansemic condition, of the retinal vessels. Chemical and micro- 
scopic investigation of the urine showed an increased amount 
of the phosphates in that excretion, otherwise the result was 
negative.'' 

The very interesting case before us to-day appears to have 
l)egun, as occasionally cases of progressive muscular atrophy 
do, with congestion of the spinal cord. Certainly the symp _ 
toms mentioned as having been present point very strongly to ' 
congestion of the nervous centres as the earlier pathological 
condition, but I do not intend at this time to dwell to any ex- 



152 CLimCAL LECTURES. 

tent upon tlie preexisting disease, but will ask yonr attention 
mainly to a condition of progressive mnscular atrophy under 
which the patient now obviously suffers. 

Although, doubtless, progressive muscular atrophy is as 
ancient as any other disease, it is only within comparatively 
recent times that its peculiar features have been pointed out, 
and that it has taken its place in the nosological list as a dis- 
tinct pathological entity. The first account of the disease we 
have was given by Duchenne (to whom we owe so much for 
his researches in the pathology and physiology of the nervous 
system) over twenty years ago. 

Cruveilhier, however, had several years previously described 
it in his lectures, and on that account the affection is frequent- 
ly known as Cruveilhier's atrophy. It is also sometimes called 
wasting palsy, and probably the instances of withered arms 
mentioned in sacred and profane history were cases of this 
affection. 

It very usually happen* that the first indication of disease 
which the patient experiences is an inability to manage his 
limbs as well as is natural to him, and he ordinarily experi- 
ences at the same time an easy susceptibility to fatigue ; the 
muscles ache upon very slight exertion, and sometimes sud- 
denly relax, allowing the patient to fall, if it be the muscles of 
the thigh or the leg which are thus affected. This feeling of 
fatigue is especially liable to be experienced in the muscles of 
the hand and forearm, and is noticeable when the patient at- 
tempts to write oi* perform any other act which requires con- 
tinuous or repeated muscular contraction ; at the same time, 
or at least very soon afterward, he is subject to neuralgic pains 
in the affected muscles ; these differ, however, from those char- 
acteristic of the first stage of locomotor ataxia in the fact that 
they are not so lancinating in character, being generally fixed 
in the muscles. 

Another early feature of the affection is what has been 
called fibrillary contraction, and indeed so common is this 
symptom that it has been regarded as pathognomonic ; certain- 
ly I have observed it in every case that has come under my ob- 
servation. It is limited to separate bundles of muscular fibres, 
and the motion in the superficial muscles can be very distinct- 



PROGEESSIVE MUSCULAR ATROPHY. 153 

It seen through the skin. Frequently the contractions succeed 
each other with such rapidity as to give the impression of a 
distinct wave-like movement, and to the patient the sensation 
is as if there were bundles of moving worms under the skin. 
If the disease shows a tendency to extend, these contractions 
are the harbingers of its progress. 

Up to this time there has been little or no atrophy, or at 
least not sufficient to have attracted the attention of the patient ; 
but, as the weakness increases, he finds that it is accompanied 
by shrinking. Now, I want you to distinctly understand that 
the loss of power is due directly to the atrophy, and is not a 
primary feature : as the muscle disappears the patient loses in 
a corresponding ratio motor power. 

It ordinarily happens that the disease begins in the upper 
extremities, and the situation of all others which it most affects 
is the ball of the thumb ; the thenar and hypothenar eminences 
disappear, and the outline of the bones of the thumb and the 
first finger can be very distinctly made out. Even when this is 
not the initial point, it rarely happens that it does not become 
involved sooner or later in the course of the disease. Probably 
the next most common place of origin is the deltoid muscle, 
and occasionally the affection begins in this part, soon after 
extending to the other muscles about the shoulder, and eventu- 
ally to those of the arm and the forearm. Beginning in one 
upper extremity, the morbid process soon involves the muscles 
of the other. 

When the disease is well pronounced, say, for example, in an 
upper extremity, the appearance presented by the atrophied 
member is very striking ; the interossei and lumbricales muscles 
having disappeared, as well as the abductors and adductors seat- 
ed in the palm and dorsum of the hand, render the outlines of 
the metacarpal bones distinctly visible ; the natural hollow of 
the palm of the hand is very much increased, and the thumb 
and fingers, being deprived of motor power, take almost any 
position in which they are placed ; the thumb especially follows 
the force of gravity and falls about in a very disorderly man- 
ner. It can no longer be brought into apposition with the in- 
dex-finger, as is necessary in the acts of writing or picking up 
a pin. 



154 CLCaCAL LECTUEZS. 

In tlie forearm the disappearance of the muscles gives rise 
to a peculiar flattening, and in the arm the outline of the hn- 
mems can be perceived without difficulty. The shoulder is 
flattened, the head of the humerus falls out of the glenoid 
cavity, and the whole contour of the joint can be readily made 
out. 

The skin, not readily adapting itself to the diminished vol- 
ume, hangs in loose folds over the attenuated muscles. It is 
nob often the case that the muscles of the face become involved, 
but, when they do, of course the physiognomy of the patient is 
very greatly altered. 

Two interesting cases, in which the upper extremities and 
the face were both involved, have quite recently come under 
my notice. 

In the case of the patient now before us. the morbid pro- 
cess is entirely confined to the muscles of the lower extremi- 
ties. In the first place, he observed the pains, the cramps, 
the fatigue, the awkwardness, and the fibrillary conti'actions, 
which so generally precede the ati'ophy. So great was his 
weakness that he was obliged to use crutches, and only after 
the disease had existed some time did he perceive that the mus- 
cles of both legs were gradually disappeai-ing. At the present 
time the extensors of the foot are almost entirely gone, as are 
the gastrocnemii and solei muscles of both legs. The lower 
third of the muscles of both thighs is beginning to disappear 
and the aftection is evidently rapidly extending upward. 

The atrophy in this patient gives rise to a characteristic 
phenomenon : 

The atrophied extensor muscles of the foot are no longer 
able to keep the toes elevated ; as a consequence they do not 
clear the ground when the patient attempts to walk, and in- 
deed the corresponding condition of the great muscles on the 
posterior aspect of the leg prevents the patient from standing 
without additional support. His ankles give way, and he 
would fall to the ground if it were not for assistance. 

You see how distinctly the shape of the tibiae and fibulae of 
both legs can be distinguished : how entirely the calves of the 
legs have disappeared, and how, owing to this atrophy of mus- 
cles, the ankles and knee-joints appear to be comparatively 



PEOGEESSIVE MUSCULAR ATROPHY. 155 

larger tlian tliey are in a liealthj person. Tims far the mus- 
cles of the thigh are not affected to any great extent, but even 
novr tlie patient has a difficnlty in extending or flexing the 
legs. 

It sometimes happens in the course of progressive muscu- 
lar atrophy that, when all the muscles of a limb are not sim- 
ultaneously involved, contractions take place. This is due 
to the fact that tlie normal antagonism existing between the 
muscles is to a certain extent destroyed. When this is the 
case in the hand, a very characteristic appearance, resembling 
the half-flexed claw of a bird, and called by Duchenne the 
77iccin en griffe^ is produced. 

The temperature of the atrophied muscles is usually several 
degrees below the normal standard ; the cutaneous capillaries 
appear to be relaxed, and consequently readily become en- 
gorged. The electric contractility diminishes correspondingly 
with the progress of the atrophy, and the reflex excitability is 
greatly lessened except in the very early stage, when it is usu- 
ally increased. 

Such are the essential features of progressive muscular 
atrophy ; sometimes its progress is slow, but ordinarily it is 
rapid. I have seen cases that have terminated fatally in the 
course of three months, and others again in which it has lasted 
for several years. 

As regards the causes, we have no very deflnite data which 
are applicable to all cases. There appears to be no doubt, 
however, that it is produced by injuries to the spine, exposure 
to cold and wet, and especially by undue muscular exertion. 
I have seen three cases where the disease made its appearance 
in the muscles of the leg in ballet-dancers, one of whom, a pa- 
tient from the E'ew York State Hospital for Diseases of the 
I^ervous System, I brought before you on a former occasion 
and lectured upon. Another you will recollect, a bricklayer, 
whose occupation requiring him to bear the whole weight of 
his body upon one leg, became affected with progressive mus- 
cular atrophy in that member ; and you doubtless remember 
the faro-dealer, in whom a like cause was in operation, and in 
whom the muscles of the hand and arm were first attacked. 

Of predisposhig causes, sex is hifluential. Nearly all my 



156 CLINICAL LECTUEES. 

cases, over forty in number, were males, and such has been 
the experience of other authorities. Age is another ]3redispos- 
ing cause, middle age and youth being especially liable. He- 
reditary influence is sometimes undoubted. 

The ballet-dancer to whom I have just alluded has two sis- 
ters aflfected with the same disease. Two cases, brothers, were 
sent to me not long ago from "Washington City. Two broth- 
ers, flfteen and seventeen years of age respectively, are now 
under my care suffering from this disease, and several others 
have had relatives similarly affected. 

As regards the diagnosis, I do not think that you will have 
much difficulty, as the symptoms are so characteristic and ob- 
vious that I do not see how you can mistake it. 

Unfortunately, the prognosis is almost uniformly unfavor- 
able ; yet still we do occasionally succeed in restoring the 
atrophied muscles, and still more frequently in arresting the 
further progress of the disease ; nevertheless it must be con- 
fessed that instances of either are exceedingly rare. 

In accordance with the general idea of these lectures, I 
shall have very little to say to you relative to the morbid anat- 
omy or the pathology. I must, however, impress upon you 
the fact that, although the disease is manifested almost entii'e- 
\j in the muscles, the affection is one essentially of the spinal 
cord ; this is its starting-point. The morbid changes are de- 
t^ected here after death, and the atrophy in the muscles is di- 
rectly the result of the pathological process initiated and going 
on in the spinal cord. I will simply say to you, in regard to 
this process, that it appears to consist in the atrophy and dis- 
appearance of motor nerve-cells, and the substitution for them 
of the neuroglia or connective tissue. 

I have, as you will remember, already given considerable 
attention in these lectures to the subject of posterior spinal 
sclerosis, or locomotor ataxia as it is more commonly called, 
and I now wish to bring before you a patient who is suffering 
from a combination of symptoms such as we find in both 
locomotor ataxia and progressive muscular atrophy. 

Case. Posterior Sjpinal Sclerosis and Progressive Mus- 
cular Atrophy. — " S. F. S-, aged thirty-seven, was born in 



POSTEEIOR SPIJS'AL SCLEROSIS, ETC. 157 

Ireland, is niamed, the fatlier of three children, and a lawyer 
by profession. 

'• A man originally of tine constitution and excellent muscu- 
lar development, from having engaged nearly all his life in out- 
door athletic sports, which he has no doubt at times earned to 
excess. He has always been temperate in his habits, and has 
never had any severe sickness, but has suffered more or less 
all his life from obstinate constipation of the bowels, which 
has been a constant source of annoyance to him. In 1858, an 
eruption appeared upon his body, which has persisted up to 
the present time, and which upon examination proved to be 
pityriasis versicolor ; it is confined entirely to the trunk, and 
consists of irregular brown patches, w^hich are most abundant 
upon the chest and back. In 1859, he had gonorrhoea, which 
was followed two months subsequently by a soft chancre, but 
there is no evidence of constitutional syphilis in the history 
of this patient, other than the scaly eruption which has already 
been mentioned. In regard to his family history, we learned 
that his mother died of puerperal fever when he was quite 
young, and that his father's death was caused by an attack of 
pneumonia some years ago. He has a brother who is an im- 
becile, but otherwise there are no members of his family who 
are afflicted w4th any of the diseases of the nervous system. 

'^ In July, 1865, up to which time he had always enjoyed 
excellent health, he went to Harlem on business, and while 
there was caught in a shower, during which he was drenched. 
In this condition he rode to Pine Street, where he re- 
mained busy writing at his office for several hours before re- 
turning home to change his clothes. Two weeks subsequently 
he was seized with a severe chill, and feeling very ill he 
returned home, and was obliged to go to bed. He now 
became delirious and remained so for about half an hour, when 
a severe diarrhoea supervened, which lasted about a month. 
He became so weak and prostrated that he determined to go 
to the Catskill Mountains in order to recuperate, and here he 
remained until he thought he had quite recovered, when he 
returned to 'New York to resume the practice of law, about 
the first of September. 

'' From this period until May, 1866, he seemed to be in 



158 CLES-ICAL LECTURES. 

good health, and attended regnlarly to his professional duties. 
. " One morning about this time, he started to run to catch 
a horse-car, when he noticed a stiffness or want of elasticity in 
his lower extremities, which he compared to the feeling ' as 
though he had on a ]3air of wooden legs.' 

" His attention having now been thoroughly aroused, he 
soon experienced numbness and coldness in these parts, and 
there soon followed incoordination, which was in direct pro- 
portion to the gradually increasing numbness, which went on 
steadily progressing until July, 1869. This want of the guiding 
j)ower over the legs was especially noticeable when the patient 
attempted to walk in the dark. There was no feeling of con- 
striction around the waist at this time, although the patient 
still suffered from constipation of the bowels. 

" During the year 1867 he commenced to have inconti- 
nence of urine, and for two years this has gradually grown 
worse. 

" In the early part of the year 1869 he first felt, especially 
at night, sharp, flashing, electric pains in the legs, which re- 
mained a variable period, and seemed to be in direct ratio to 
the amount of physical exercise which he had taken. These 
have been present at intervals up to the time that the patient 
entered the hospital for treatment. In July, 1869, he was 
suddenly seized with strabismus accompanied with double 
vision, and ptosis of the right eye. The j)tosis, however, still 
persists, although the strabismus and double vision had com- 
pletely disappeared after the lapse of six months. 

" It was not until 1867 that he was aware of any differ- 
ence in the muscular power of his legs, although for the last 
year he had noticed that there was a well-pronounced want of 
coordination irw the lower extremities, and that this- power of 
directing the voluntary muscular movements was far from 
being under his control. 

" This disparity, however, became gradually more marked, 
so that in the course of a year there was a decided diminution 
in the size of the left leg, which was greatly atrophied, although 
the right was not at this time perceptibly implicated. jS^ow 
his venereal appetite began to be impaired, and in June, 1869, 
he was conscious that the seminal emissions in the act of copu- 



FOSTEEIOR SPIJS'AL SCLEEOSIS, ETC. 159 

latioii took place very quickly, altlioiigli there was no aptitude 
for repeating the venereal act. He had never had noctnmal 
emissions ; prior to the year 1869 he had never had any sharp 
electric pains nor any ocular troubles. Since July, 1869, the 
loss of muscular power has been very slight in his lower ex- 
tremities ; about this time he was seized with a severe pain 
in the left arm, and there soon followed numbness, which has 
gone on progressively increasing, and which has been accom- 
panied with a corresponding impairment of motility in that 
member." 

Such was the history of this case up to the time of his 
admission into the out-door department of the 'New York State 
Hospital for Diseases of the ISTervous System, I^ovember 9th, 
1870, when his condition was found to be as follows : 

'' There was ptosis of the right eyelid, which appeared to 
vary in degree from time to time. The patient experienced 
a peculiar feeling in the right eye, as though a foreign body 
were present, and acting as a source of irritation, yet upon 
careful examination no conjunctivitis, granular lids, or other 
extrinsic cause for this abnormal sensation, could be discov- 
ered. There was also a slight diminution in the reflex ex- 
citability of the conjunctiva of the right eyeball. The pu- 
pils, however, were equal and responded readily to light. 
There were no other aberrations of vision, and all the remain- 
ing special senses were normal excepting tactile sensibility, 
which was very much impaired. His mind was active and 
his memory was very retentive. The electric pains occurred 
less frequently than formerly, and were shorter in duration 
and less severe in character. There was a great degree of 
incoordination in the left upper and lower extremities, more 
particularly in the latter, but the characteristic gait of the 
ataxic patient was not prominently marked, having been more 
or less modified by the superaddition of progressive muscular 
atrophy which obscured the ataxy. 

" The dynamometer indicated a difference between the 
muscular power in the two hands, the left being much weaker 
than the right, which w^as also more or less involved, as the 
index plainly demonstrated. Although there was at this time 
loss of power in his left hand, yet the want of coordination 



160 CLINICAL LECTURES. 

was exceedingly well marked whenever he attempted to per- 
form any of those complex movements which require the nice 
management of the lingers, such as buttoning his collar, pick- 
ing up a pin, and the like, and which depend upon exact co- 
ordination of the muscles for their perfect execution. Even 
these acts he could not accomplish with his left hand unless he 
was aided by the sense of sight. He could with the tip of the 
index-finger of the right hand, and when his eyes were closed, 
touch any spot of his body indicated, as for example the end 
of the nose, but this he could not do with the left hand, which 
showed that he did not possess a knowledge of where the diifer- 
ent parts of his body were situated when he employed that 
member. On placing a weight of an ounce in his left hand and 
then removing it and replacing it by by a weight of four ounces, 
he was unable to tell which was the heavier of the two when his 
eyes were closed, although in his right hand he could appreci- 
ate quite readily which was the heavier. He could write with 
his right hand very nicely, and there was no material change 
to be observed in the formation of his letters, yet he could not 
continue at that occupation for any length of time without ex- 
periencing a sense of great fatigue which compelled him to re- 
linquish what he could formerly accomplish very easily. He 
had no pain in the back, no feeling of constriction about the 
abdomen or any other part of his body, no spasms, no fibrillary 
contractions or quiverings of the muscles. His sexual appetite 
was now nearly abolished, and the incontinence of urine had 
increased to such an extent that it continually dribbled away 
and soiled his clothes. He could not walk in the dark, nor 
could he stand with his eyes closed, even when his feet were 
spread widely apart so as to increase his base and give him a 
firm support. There was marked anaesthesia in the soles 
of his feet, as there was in all the other parts of his body 
below the first dorsal vertebra. On measuring the tactile 
sensibility in the back, the points of the assthesiometer 
could barely be distinguished at four inches, in the lower ex- 
tremities at three and a half inches, in the forearm at three 
inches, and in a corresponding ratio the tactile sensibility was 
diminished in all parts of the body below the point mentioned. 
There was also great impairment of the sensation of pain, or 



POSTERIOE SPINAL SCLEEOSIS, ETC. 161 

mtlier a retardation in the transmission of that sensation to 
the sensorium which was marked by an interval of over five 
minutes. For example, on pricking his leg with a needle, he 
was not aware of that fact nntil at least five minntes had 
elapsed, and then he wonld begin to feel the pain very 
acutely, and would refer to the exact locality where I had in- 
flicted the injury. "When one of the sponges of a galvanic 
current of sixty cells was applied to the back of this patient, 
and the other to his leg, it was fully fifteen minutes before he 
appreciated the normal effect of the galvanism, but imme- 
diately he experienced an uncomfortp.ble sensation as though 
he had been immersed in ice-water. The temperature in the 
left leg was less than in the right, both being several degrees 
below the normal standard, and the capillary circulation was 
very languid, as shown by the coldness and lividity of these 
parts. The reflex excitability in the hands and feet was nearly 
abolished. Physical exploration of the heart and lungs re- 
vealed a healthy condition of the former, but the latter organs 
were filled with coarse mucous rdles^ which were equally dis- 
tributed over both sides of the chest. His bowels w^ere regular, 
and had been for some time past. About a year ago he com- 
meneed to have a s]ippressed dry cough, but this only lasted a 
short time. There was a huskiness of the voice which had 
attracted his attention for about a year, but there w^as no other 
evidence of phthisis. 

" The atrophy in this case began first in the left foot, and 
then extended upward, gradually involving the flexors and 
extensors of the leg and thigh, together with the glutei mus- 
cles on that side. It now passed over to the opposite side and 
invaded the same group of muscles in the same order as it had 
done in the other limb. It next attacked the muscles of the 
left hand, foreafm, and arm, together with those about the 
shoulder, but in what order the patient was not aware ; and 
then it invaded the muscles of the right upper extremity, 
as evinced by the weakness and sense of fatigue which have 
already been mentioned. On attempting to flex the legs of 
this patient, it was found that he was able to offer considerable 
resistance ; but, when his legs had once been flexed, they could 
be extended with the greatest ease, from which fact we learn 



162 CLINICAL LECTUEES. 

that the flexor muscles are much more degenerated than the 
extensors. In regard to the muscles implicated, it is hardly 
necessary to state that the atrophy varied in degree not only 
in the different muscles attacked, but also in various portions 
of the same muscle, although corresponding parts on the two 
sides were demonstrated by means of the galvanic current to 
be impaired. In the left leg, where the atrophy first com- 
menced, the disease was most advanced, and the muscles of 
that foot were so completely destroyed that its bony outline 
was perfectly apparent." 

After the cases which I have exhibited to you of posterior 
sclerosis of the spinal cord and progressive muscular atrophy, 
you will not expect me to make any very extensive remarks 
in regard to this case. It is interesting, however, as exhibit- 
in o^ to some extent the existence of the two diseases in the same 
individual. 

Apparently the left half of the spinal cord is more involved 
than the right. The motor fibres are contained in the ante- 
rior columns as far np as the anterior pyramids, where they 
decussate, and that accounts for the paralysis with atrophy of 
the left leg. 

The sensory fibres, which are contained in the posterior 
columns, decussate soon after their ," entrance into the spinal 
cord, and that fact accounts for the loss of sensibility and the 
other symptoms of locomotor ataxia, which are most conspic- 
nons in the left leg and arm. Doubtless the other half of 
the spinal cord is likewise implicated, but the more striking 
faets are as I have mentioned. 

^^ You will have observed also that, although the disease in 
this case has not had an intra-cranial origin, there have been 
and still are symptoms indicative of intra-cranial disturbance, 
chiefly those due to a paralysis of the third pair of nerves of 
the right side. 

This is to be accounted for by the intimate anatomical re- 
lation which exists between the sympathetic nerve and the 
spinal cord, a certain part of which, extending from about the 
third cervical to the third dorsal vertebra, is called the cilio- 
spinal centre — injury or disease of this portion of the spinal 



POSTERIOR SPI:N^AL SCLEROSIS, ETC. 163 

cord being usually accompanied by disturbances of vision such 
as tliose exhibited in the case before us. 

The history of the case up to the present time is so full 
and explicit that it is not necessary for me to dwell further 
upon its phenomena. Before, however, closing my remarks 
upon this subject, I wish to call your attention to the treatment 
of this disease, which I shall now proceed to consider. In the 
lirst place, our main reliance is in the use of the primary gal- 
vanic current, which should be applied every alternate day to 
the spinal cord, the negative pole being placed above the dis- 
eased portion of the cord and the positive below. The sympa- 
thetic nerve should also be thoroughly galvanized, the negative 
pole resting upon the cervical ganglia in the neck, and the 
positive upon the cilio-spinal centre. .The duration of these 
applications should vary from live to ten minutes, and should 
be sufficiently strong to produce a moderate degree of pain. 
I also employ both the primary galvanic and the faradic cur- 
rents, applying the sponges either directly to the atrophied 
muscles or to the nerves which supply them, in order to improve 
their nutrition and keep up their development as much as 
possible until the spinal cord has sufficiently recovered its tone, 
so that they can then readily respond to the stimulus sent 
out from that nervous centre. You know that I have striven 
to impress upon your minds that the disease is situated in the 
spinal cord primarily and not in the muscle, and that is the 
reason why we direct the galvanism mainly to the spinal cord 
and sympathetic nerve. In addition to this mode of treat- 
ment, I have been in the habit of giving phosphorus in doses 
of the sixtieth of a grain, three times a day, either in the 
form of phosphoric acid, oil of phosphorus, or phosphide of 
zinc. The chloride of barium is another excellent remedy in 
sclerosis of the brain or spinal cord, and from my experience 
with this agent I am inclined to regard it very highly. It 
should be administered in doses of a grain dissolved in a 
drachm of the tincture of hyoscyamus, which should be given 
three times a day in water. Cod-liver oil is always advan- 
tageous, and in conjunction with the phosphorus is necessary 
to supply the essential elements to the diseased tissue. Where 
there is a history of the existence of a syphilitic taint, the 



164 CLtXICAL LECTUEES. 

iodide of potassium should be given, in gradually-increasing^ 
doses, in combination with corrosive sublimate, as I have al- 
ready recommended to you in a previous lecture. The pa- 
tient should be instructed not to tax too severely the atrophied 
muscles by over-exercising them, as by this means he readily 
exhausts the already-impaii-ed nervous force of the spinal 
centre. If the patient be seen in the very first stage of the 
disease, when the cord is congested, ergot is the proper remedy 
to be used, and remember to give it in large doses, say a 
drachm of the fluid extract thrice daily. 

Before we can expect any amelioration in the symptoms, 
it is necessary to continue our treatment for a month or two 
at least ; but, in order to arrive, at a cure, the treatment must 
be extended to months, or even years. 



LECTUEE XIII. 

COXYULSIVE TEEMOK. 

J. X., the patient before you, is a well-nourished, healthy 
young man, a farmer by occupation. You have only to look 
at him to see that he cannot be the subject of any serious or- 
ganic disease, and yet he is suffering from an affection which, 
to say the least, is very inconvenient, if not alarming. 

At periods varying from a few weeks to several months, he 
is subject to violent convulsive movements in almost all the 
muscles of his body, and unattended, except in one instance, 
by loss of consciousness. The paroxysms last several hours, 
and during their continuance the patient, owing to the violent 
jactitations into which his limbs are thrown, is totally unable 
to execute voluntary movements. He is even unable to stand 
without support, and cannot guide either his hands or feet. 
The muscles of speech are likewise affected, and he is conse- 
quently unable to articulate distinctly the words he may at- 
tempt to utter. While all this is going on, his body is bathed 
in cold perspiration and the circulation is accelerated; the 
respiration is increased in frequency and there is well-marked 



CONVULSIVE TREMOE. 165 

and persistent pain in tlie back of the head and nape of the 
neck. 

He is yerj positive that, except in the one instance to 
which reference has been made, he is entirely conscious, and 
JQst as capable of accurate reasoning as he ever is. 

On the occasion of loss of consciousness, the paroxysm had 
lasted several hours ; he was in consequence very much ex- 
hausted, and therefore he may have been suffering from 
simple syncope : still, it is possible that the attack in question 
may have been epileptiform in character. He has been sub- 
jected to various kinds of medical treatment, but nothing has 
appeared to be of any service. The last attack was about 
three months ago, and he says it may be three or four months 
before he will have another attack. He has suffered from the 
affection since the year 1866, a period now of over six years. 

According to his description of the attacks, the muscles 
are affected very much as those of persons suffering from 
chorea of a very violent character ; and yet it is evident that 
the disease is not chorea, for the clinical history of that affec ■ 
tion does not include such entire remissions as part of its phe- 
nomena. 

It certainly is not epilepsy, although it must be confessed 
that it borders upon it ; but the essential feature of epilepsy, 
loss of consciousness, has never been present in any one of its 
paroxysms unless it was a feature of the occasion already 
mentioned, and relative to which there is some doubt ; for, 
when we come to question him specifically in regard to loss 
of consciousness, he is not very decided in his answers. 

With the other affections in which tremor and tonic 
spasm are prominent features, the disease in question has no 
affinity. 

I^ow, this case is not the first of the kind which has come 
under my observation. In the New Yoek Medical Journal 
for June, 186 T, in an article entitled " Convulsive Tremor," I 
gave the clinical histories of three ver}^ similar cases, and as 
the affection is not very common, and the disease may be en- 
tirely distinct from any other, it will not be uninteresting if I 
briefly relate to you not only the main points of my own 
cases, but likewise what was previously known upon the 
subject. 



166 CLmiCAL LECTURES. 

In the year 1822 Dr. Pritcliard/ under the name of con- 
vulsive tremor, gave an account of two cases, presenting some- 
what similar features to the one before us. His attention was 
first directed to the subject by noticing that, in some epileptic 
patients who had come under his observation, fits of tremor 
occurred in the intervals between the paroxysms and even 
appeared to take the place of the ordinary seizure. He then 
noticed several cases in which there were no epileptic attacks, 
but in which there were violent clonic spasms of the muscles, 
accompanied with severe pain in the head and profuse perspi- 
ration. Dr. Pritchard states that, previous to his observations, 
the affection had not attracted much attention ; but he cites a 
case from Tulpius ©f a young unmarried woman, of a pale 
complexion and phlegmatic temperament, who was afflicted 
during three years with what was called the shaking palsy, 
which did not affect her constantly, but came on in periodical 
fits ; each paroxysm lasted nearly two hours, and was accom- 
panied by hoarseness and loss of voice, the consciousness being 
unimpaired. 

He also refers to other cases quoted by Sauvages from 
Bonetus, in which the symptoms were very similar, consisting 
of convulsive tremor, attended with headache and vertigo. 
This disorder was fatal in a few days, and after death a para- 
site was found in the brain. In this connection it is interest- 
ing to recall the fact that the sheep is subject to a somewhat 
similar train of symptoms, due to the presence of an entozoon 
in the brain. 

In his very excellent treatise on the shaking palsy, Par- 
kinson,'^ in calling attention to the fact that several diseases 
characterized by tremor have been confounded with paraly- 
sis agitans, quotes the following case from Dr. Kirkland : 

Mary Ford, of a sanguineous and robust constitution, had 
an involuntary motion of her right arm, occasioned by a fright, 
which first brous^ht on convulsion-fits and most excruciating 
pain in the stomach, w^hich vanished on a sudden, and her 
right arm was instantaneously flung into an involuntary and 

^ " A Treatise on Diseases of the ISTervous System, " London, 1822, p. 393. 
' "Essay on the Shaking Palsy," London, 1817, p. 29. 



CONYULSIYE TREMOE. 167 

perpetual motion like tlie swing of a pendulum, raising the 
hand at every vibration higher than the head ; but, if by any 
means whatever it was stopped, the pain in her stomach came 
on again, and convulsion-fits were the certain consequence, 
which went off when the vibration of her hand returned." 

Parkinson also quotes another case from the same source, 
resulting apparently from worms, and which is thus described : 

" A poor boy, about twelve or thirteen years of age, was 
seized with a shaking palsy. His legs became useless, and 
together with his head and hands were in continual agitation ; 
after many weeks' trial of various remedies, my assistance was 
desired. His bowels being cleared, I ordered him a grain of 
opium a day in the gum-pill ; and in three or four days the 
shaking had nearly left him. By pursuing this plan, the 
medicine proving a vermifuge, he could soon walk, and was 
restored to perfect health." 

Toulmouche,^ in a paper which is very suggestive in the 
light of recent contributions to neurological pathology, cites a 
case which is likewise similar to the one now before us : 

" A woman, whose respiration was convulsive, presented 
from time to time the following condition : Her nostrils were 
strongly dilated, the angles of the mouth drawn down, the 
shoulders and chest spasmodically elevated, the inspiration 
strong and deep, the sterno-cleido-mastoid muscles were power- 
fully contracted. During these paroxysms, which lasted sev- 
eral minutes, the patient was deprived of the faculty of speech 
and threatened with suffocation. N'evertheless, she could, if so 
directed, move the head, the shoulders, and the muscles of the 
face, although the spasm continued. ... In another case the 
affection, was almost entirely confined to the sterno-cleido- 
mastoid muscle. The patient could turn the head in either 
direction, but gradually it moved from right to left, without 
her ability to control its action, so that the right ear almost 
rested upon the sternum. Tlie other muscles of the shoulder 
contracted at the same time. He likewise reports another case 
in which the head was almost continually in motion, the pa- 

^ "Observations de quelques Fonctions involuntaires des Appareils de 
la Locomotion, et de la Prehension. Memoires de I'Academie Royale de 
Medecine." Tome deuxieme. Paris, 1833. 



168 CLINICAL LECTURES. 

tient executing twenty-two rotations in a minute ; the move- 
ment was due to the alternate contraction of the sterno-cleido- 
mastoid and splenius muscles of each side ; respiration was not 
obstructed. The movements diminished and finally ceased, 
after two or three attacks of hsemoptysis." 

The concusion which the author draws from his own cases, 
and those which he cites from other authorities, are mainly 
interesting in relation to his theory of the pathology. They 
are — 1. That there exist for the movements of our different 
groups of muscles different central motor forces. 2. That the 
cerebelhnn only presides over the coordination of those com- 
plex movements which are necessary to the different acts of 
standing and locomotion, and not at all over those that regu- 
late the more simple movements of the trunk and the mem- 
bers. 3. That this nervous centre is to vertebrate animals the 
power to maintain themselves in equilibrium and to exercise 
locomotion. 4. That, if, in the species of neurosis that I have 
described, the sensation and intellectual faculties experience 
no change, this fact is due to the circumstance that the lesions 
of the cerebellum have not yet involved the tubercular quad- 
rigemina. That these last-named organs are in a kind of de- 
pendence upon the brain, since in the normal state animals 
move through the impulsion of various motives of which 
the brain is the seat. 5. That finally a number of affec- 
tions, called nervous, consisting in the most erratic derange- 
ments of the muscular functions, such as an irresistible ten- 
dency to go backward or to advance without rational motive, 
to leap, to perform other disorderly movements, constitute 
only a species of insanity, or aberration of the locomotor func- 
tions, depending on an affection, either organic or functional, 
of the cerebellum. 

I have quoted these conclusions of Toulmouche in full, 
more as evidence of the fact that he was disposed to locate 
the seat of these troubles in the cerebellum than as intending 
to indorse his collateral hypotheses. It would be easy to 
quote other instances more or less similar to those we have 
before us, but I will simply refer to some later cases, and then 
pass to the consideration of treatment. 

Dr. Hughlings Jackson, as appears from a clinical lecture 



COI^VULSIVE TEEMOR. 169 

published in December, 1871, in the London Medical Times 
and Gazette^ brought forward a bo j, aged . fifteen, who w^as 
admitted into the London Hospital in January, 18Y1, the sub- 
ject of epileptiform convulsions, confined to the right side of 
the body ; he was also aphasic. It is stated that the parox- 
ysms began in June, 1869, in '^ the more external fingers of 
the riffht hand." Dr. Jackson also refers to several other sim- 
ilar cases which he has published from time to time since 
1867. 

These cases he regards as simply unilateral epileptiform 
convulsions, and he embraces them all under the title of epi- 
lepsy of the corpus striatum. They ordinarily begin in the 
hand which the patient is the more accustomed to use, and es- 
pecially the thumb and index-finger. The face and the tongue 
are sometimes primarily attacked, rarely the foot, and then 
always the great-toe. These cases have not a great deal of 
connection with the one before us, they have none at all with 
the disease w^hich I have described as athetosis, and to which 
a French writer ^ rather hastily likens them probably because 
no cases of either disease have come under his observation. 
A case, however, which has some analogies to the one before 
us, is now under ray charge. It is that of a boy from North 
Carolina, who has spasmodic muscular contractions confined 
to the left side, and mainly afiecting the muscles of the face, 
neck, and upper extremity. The duration of a paroxysm never 
exceeds half a minute, and there is not the least loss of con- 
sciousness. These paroxysms may be brought on by simply 
touching his neck lightly on the left side of the thorax. At 
intervals of two or three months he has one or more perfectly - 
marked epileptic convulsions. But even this case I do not 
regard as identical with the instances of purely convulsive 
tremor which have come under my observation, though doubt- 
less there is a family resemblance. 

In the paper to which reference has been made as pub- 
lished in the I^ew Yoek Medical Journal, I gave it as my 
opinion that the affection described " depended upon a dis- 

^ "Dictionnaire Anuuel des Progres des Sciences et Institutions Me 
dicales suite et complement de tous les Diction naires," par M. P. Garnier. 
Paris, 1873. Art. Athetose, p. 42. 



170 CLIT^ICAL LECTUEES. 

order of tlie cerebellum, unattended with any serious organic 
lesion, and consisting essentially in congestion of some limited 
portion of its substance." While still disposed to regard its 
seat as being in the cerebellum, I am not so sure that it is 
always the result of congestion. Indeed, several similar cases, 
which subsequently came under my care, were aggravated by 
the use of the bromide of potassium, which as you know less- 
ens the amount of the intra-cranial blood, and they were 
cured by means calculated to increase the amount of blood 
in the brain and spinal cord. Consequently I am induced to 
think that cerebral anaemia may be one of the pathological 
conditions capable of giving rise to convulsive tremor. The 
pathology, however, must remain more or less obscure until we 
have the opportunity of verity ing our diagnosis hj post-mor- 
temi examinations. 

In the cases described in the memoir to which reference 
has been made, the measures which were found efficacious 
were — 1. Counter-irritation by means of a seton in the nape of 
the neck ; 2. Large doses of the bromide of potassium ; 3. 
The primary galvanic cm-rent. In two of the cases, as there 
was a generally anaemic condition, iron and quinine were 
also administered. In one case the bromide of potassium 
produced no perceptible effect, and the tincture of hyoscy- 
amus was substituted for it, with good results. 

In the case of the young man before us, I am inclined to 
think from his general aspect, and especially from the fact of 
the extremely dilated state of his pupils, that there is cerebral 
anaemia, although his general system gives no indication of de- 
bility. He is obliged to leave town immediately, and I can- 
not, therefore, subject him to an ophthalmoscopic examination. 
I propose, therefore, to act tentatively upon the theory of 
cerebral anaemia, and to treat him with strychnia in gradually 
increasing doses ; a plan of treatment which is eminently suc- 
cessful in the analogous affection chorea, and occasionally even 
in epilepsy. We will, therefore, direct that a solution of the 
sulphate of strychnia, in the proportion of two grains to the 
ounce of water, be made, and that of this the patient shall 
take the first day ten minims three times ; this will give him 
the twenty-fom'th of a grain at a dose. The next day he will 



CHRONIC BASILAE MENmOITIS. 17 1 

take eleven minims at each dose, the next twelve, the next 
thirteen, and so increasing in like manner till the physiolo- 
gical effect of strychnia be produced. This will consist in 
slight rigidity of the muscles of the calves of the leg, and per- 
haps of those of the neck and jaws. When this effect ensues, 
the dose is to be dropped to the original quantity of ten minims, 
which is to be gradually increased as before, and so on till the 
period for the occurrence of the paroxysm is passed. Should 
this plan of treatment be successful in preventing an attack, it 
ought to be continued for several months longer. I may state, 
in conclusion, that there is not the least danger in carrying out 
this system of treatment. It simply requires ordinary care 
and prudence. • \ 

KoTE. — Three months after the delivery of the foregoing 
lecture, the patient reported that he had had no paroxysm ; it 
had generally taken from thirty to thirty-five minims of the 
solution of the strychnia to produce the physiological effects. 
He also reported that his general health had never been better, 
and that he was working assiduously on his farm. The 
therapeutical promise is therefore good. 



LECTUEE XIY. 

CHRONIC BASILAR MENINGITIS. 

The patient whom I have now the opportunity of show- 
ing you, first made her appearance at this clinique in the 
winter of 1871-'72, about a year ago. At that time she 
was suffering from deep-seated pains in the head, vertigo, 
and paralysis of the third nerve on the left side, as evidenced 
by ptosis, dilatation of the pupil, and external strabismus ; the 
latter condition producing diplopia. Conjoined with these 
symptoms there was slight but decided paralysis of the mus- 
cles of the face, arm, and leg of the opposite side, together 
with cutaneous anaesthesia. 

The history of the case was not that of cerebral haemor- 
rhage, or embolism, for inquiry showed that the symptoms 



172 CLINICAL LECTUEES. 

had been of very gradual development, a fact not consistent 
with the existence of either of the lesions mentioned. I was 
disposed to think that the affection was an aneurism of the 
left posterior communicating, or posterior cerebral artery, both 
of which, as you know, are in very intimate topographical re- 
lation with the crus cerebri, a tumor of some other kind in- 
volving the left crus or pressing upon it, or chronic basilar 
meningitis with effusion, implicating the same part. I re- 
garded the latter as the most probable morbid condition, for 
the reason mainly that the symptoms were not so intense as 
regarded paralysis and pain as are those which result from 
either of the other diseases named. 

Tlie explanation of the phenomena o^bserved in this case, 
some of you will doubtless recollect ; but, as the patient illus- 
trates important physiological and pathological facts, and as 
most of you have not seen her before, it will not be out of 
place for me briefly to touch upon the relation of the observed 
symptoms to the supposed pathological condition. 

In the first place there were ptosis, external strabismus, and 
dilated pupil of the left side. These circumstances indicated 
the involution of the third pair of nerves in the lesion, proh- 
dbly of the same side, even if there were no accompanying 
symptoms, but with these latter, with very considerable cer- 
tainty. 

The third pair of nerves has its apparent origin in the 
crura cerebri — the right nerve from the right crus, and the left 
nerve from the left crus. If, however, the fibres be followed 
out by minute dissection, as has been done by Yulpian, they 
are seen to be arranged into three groups. Of these the 
middle and posterior decussate after passing entirely through 
the crus, while the anterior group passes forward to the optic 
thalamus, in which ganglion the fibres are lost. N^one of the 
fibres of origin originate in the crus, and this latter may be 
entirely dissected away, and the third nerve be left intact. 

Now, if Yulpian be right in his view that a considerable 
number of the fibres of the third nerve decussate, any dis- 
ease of the brain affecting these fibres must be manifested 
by paralysis of the muscles supplied by the nerve of the oppo- 
site side, and, as the motor and sensory fibres of the spinal 



CflEOlS^IC BASILAR MENINGITIS. 173 

cord decussate below the point at which the third nerves de- 
cussate, the disease, if causing paralysis of other parts of the 
body, would induce this condition also on the opposite side, or, 
in other words, on the same side with the paralysis of the 
muscles supplied by the third nerve. But in the case before 
us the reverse is the fact, the muscles of the eye and those of 
the face, arm, and leg, being affected on opposite sides. The 
disease, therefore, whatever its nature, must be confined en- 
tirely to the left side of the brain. 

The left crus cerebri contains motor and sensory fibres 
coming from the right side of the body, below the medulla 
oblongata. It contains the fibres of the left third nerve ; dis- 
ease involving the left crus would, therefore, cause paralysis of 
the muscles supplied by the left third nerve, and of motion 
and sensation in the left half of the body. And this is ex- 
actly what existed in the patient before us a year ago. 

As we have seen, the anterior group of the fibres of origin 
of the third nerve come from the optic thalamus of the same 
side, and a lesion affecting this ganglion would give rise to a 
similar condition so far as the paralysis is concerned. But it 
is difficult to conceive what morbid process could go on in the 
optic thalamus, and cause such a group of phenomena, so 
gradually developed as those which mark this case, and not at 
the same time produce more extensive disturbance. Taking 
all the facts into consideration, I thought the theory of basilar 
meningitis, involving the left crus, the most probable; and 
when we come to consider the present state of the patient we 
shall find strong confirmatory evidence of the correctness of 
this opinion. 

At the time to which I am now referring, I prescribed 
the use of the iodide of potassium in large doses, but gave an 
unfavorable prognosis. I was therefore somewhat surprised to 
find her to-day in the anteroom with the other patients, and, 
to cursory examination, in about the same state as she was 
this time last year. 

But a very slight inspection suffices to convince us that 
she is differently affected, for we see that the left eye is now 
rotated inward, showing, therefore, that the sixth pair of nerves 
has become involved, producing paralysis of the external rec- 



174 CLimCAL LECTUEES. 

tus muscle; the disease, whatever its nature, has shifted its 
site, and with the change of location there is a corresponding 
change in the symptoms. It need scarcely be said that such 
a circumstance is altogether inconsistent with the existence of 
a tumor of any kind, and is only reconcilable with the theory 
of meningitis with exudation. 

It is not necessary to presuppose any very extensive 
change in the situation of the disease. To be sure, the origin 
of the sixth pair at the upper border of the medulla oblongata 
and below the pons Varolii is quite remote from that of the 
third pair, but the two nerves are in very intimate topograph- 
ical relation to each other throughout a great part of their 
course ; they leave the cranium through the same aperture, the 
sphenoidal fissure, and even within the orbit are in close con- 
tiguity. This change in the situation of the lesion is, I think, 
one of the prominent features of chronic basilar meningitis. 

You will also recollect the case of the young man who 
during the past year has appeared several times before you. 
He came to me originally with external strabismus, ptosis, 
and dilatation of the pupil, affecting the left eye, with the most 
intensely agonizing pain in the head that has ever come under 
my observation. He had also vertigo, frequent attacks of 
vomiting, and paresis, if not paralysis of the arm and leg of the 
same side. A consideration of his condition led me to the 
diagnosis of a cerebral tumor, and I accordingly gave a very 
unfavorable prognosis. I was led to this conclusion, not so 
much from the motor ial derangement, as by the atrocious 
cephalalgia from which the patient suffered. In this case 
there was some slight suspicion of syphilis, and I treated him 
with mercury and large doses of the iodide of potassium. In 
a short time the pain in his head disappeared, and in a few 
weeks there were no indications of paralysis anywhere — in 
fact, he was to all appearance perfectly cured ; but at the end 
of two or three months he reappeared, with the corresponding 
set of symptoms in the right eye and the right half of the 
body, and with pain in his head fully as severe as that which 
characterized the previous attack. I again treated him with 
mercury and the iodide of potassium, and his symptoms 
again disappeared, and up to the present time thel^e has been 



no recurrence. 



CHEONIC BASILAR MENINGITIS. 175 

I have now under my care a gentleman, belonging to the 
legal profession of this city, who has attacks of acute pain in 
the head, accompanied with all the phenomena of paralysis 
of the left third nerve. Curiously enough, these attacks alter- 
nate with an eczematous afiection, involving the trunk, espe- 
cially the breast. On the disappearance of the skin-disease, 
under remedial measures, his head-symptoms immediately re- 
cur ; and when they are relieved, as they are by thp action of 
the iodide of potassium, he is again attacked with the eczema. 

In this case I presume there is an actual transference of 
the disease from the brain to the skin, and vice versa. 

In a case which I saw a few days ago in consultation with 
Dr. Hermann Knapp, the eminent ophthalmic surgeon, the pa- 
tient, a young man of whom there was no history or even sus- 
picion of syphilis, at first became attacked with disease of his 
brain, characterized by pain and obscureness of vision. Next 
there was paralysis of the muscles supplied by the third pair 
of nerves, then the fourth pair became involved, then the 
fifth, as evidenced by anaesthesia of the face, and paralysis 
of the masseter and temporal muscles, then the sixth and 
eventually the seventh and eighth, producing loss of hearing, 
and paralysis of both sides of the face. In this very remark- 
able case, there was a gradual advance in the disease, through 
a period of several weeks, along the base of the brain, from the 
anterior to the posterior region. With all these symptoms, 
there was not the slightest mental derangement. Shortly 
after I saw him, the pneumogastric nerve became implicated 
in the lesion, and death took place soon afterward. Unfor- 
tunately, there was no jpost-mortem examination, but Prof. 
Knapp and myself agreed that the case was one of inflamma- 
tion of the membranes covering the basilar surface of the 
brain. 

Now, there is one point to which I especially desire to 
call your attention, and a careful consideration of which will 
do much to prevent you from making any serious mistake 
relative to the part of the brain .involved in the morbid pro- 
cess. 

The upper or convex surface of the brain is particularly 



176 CLINICAL LECTUEES. 

connected witli the evolution of that part of the mind known 
as the intellect. 

In meningitis affecting the membranes covering this up- 
per surface, we should expect a priori that the chief mani- 
festations of brain-disorder would be shown in the direction of 
mental aberration, and in fact we find that such is really the 
case. 

The lower, the basilar, or concave surface, of the brain is 
not so much in relation with intellection as it is with sensa- 
tion and motioD, hence we should expect to find that a menin- 
gitis affecting this surface of the brain w^ould more especially 
produce deviations from the normal standard in sensation, 
motion, or both. In practice we find that these effects are 
produced. Take, for instance, the cases before us, and we per- 
ceive that the chief manifestations of disease are alterations in 
sensibility and paralysis of some one or more muscles of the 
body. You will observe, too, another prominent feature, and 
that is, that in all of them some of the muscles of the eyeball 
have been notably affected. Sometimes conjoined with pain in 
the head there is anaesthesia of distant parts, and sometimes in- 
stead of paralysis there is muscular spasm or convulsion. 

Thus in thirty-two cases of meningitis of the base of the 
brain, attended with serous or gelatiniform exudation, collected 
by Gintrac, there was not one in which convulsion or paralysis 
was not a prominent feature. 

From a very complete summary made by this author, I 
extract the following remarks relative to symptoms : 

" Headache is one of the most common. It occurred in 
more than two-thirds of the cases ; the pain was deep-seated 
and more or less severe ; sometimes it was located in the fore- 
head, sometimes in the occiput, and again in the supra- or infra- 
orbital regions. 

. " The patients often expressed their sufferings by sharp and 
almost characteristic cries. 

" There has been sometimes loss of consciousness or stupor, 
but in the majority of cases the intellect has retained its ordi- 
nary activity even to a verj advanced period of the disease. 
Delirium occurred in about one-third of the cases, and was light 
in character. A disposition to sleep was manifested very often. 



CHEONIC BASIL AB MENINGITIS. 177 

even in the early stages, but in two cases there was persistent 
insomnia. In some of the patients, speech was embarrassed, 
slow, infrequent,, or the articulation difficult. In four cases it 
was entirely abolished. 

" The phenomena offered by the visual apparatus were very 
varied and worthy of attention ; their source is found in the 
very seat of the disease. The eyes are intolerant of Hght, the 
conjunctival vessels injected, and the surface covered with a 
thick, viscid mucus ; they are prominent, and often one is more 
so than the other. One of the upper eyelids is often paralyzed, 
generally the left. The eyeballs are usually turned upward, 
rarely downward ; sometimes they roll convulsively. In more 
than a third of the cases they deviated from their normal axis, 
and thus strabismus was produced. The pupils are insensible 
or oscillate ; they were dilated thirty times, and contracted four 
times. Often they are unequal, the one being dilated and the 
other contracted simultaneously or alternately. Diplopia and 
amblyopia existed to diverse degrees from the first, or in the 
course of the disease in every case. 

" The other senses have been rarely affected. In one case 
there was anosmia, with preservation of the tactile sensibility 
in the pituitary membrane. In two cases deafness ; but if 
sometimes the patients were spoken to in a loud voice, and did 
not respond, it was perhaps rather due to the state of the in- 
tellect, than to the paralysis of the auditory nerve. 

" Convulsions were noted in twenty cases ; the spasms were 
general or partial, affecting a limb, or the face, or the eyes, or 
the organs of deglutition or respiration ; if in other cases there 
were not prominent convulsive movements, there were tremors, 
subsultus, and carphologia, grinding of the teeth, trismus, 
with stiffness of the neck ; opisthotonos was occasionally ob- 
served. In one case the head was spasmodically flexed on the 
chest, and could not be drawn back without causing great pain. 
Tonic spasms of the muscles of the arm, forearm, legs, or face, 
were observed in three cases. Paralysis, exclusive of the 
muscles of the eyes or upper eyelids, was rare. There were 
three cases of hemiplegia, one of paraplegia, one of an upper 
limb, and one of a lower limb. 

" Hypersesthesia was rare, ansesthesia much more frequent. 



178 CLIJsriCAL LECTUKES. 

" Yomiting occnrred in fifteen patients. Difficulty of swal- 
lowing in seven. Respiration was difficult, irregular, or sterto- 
rous, in every case. In a tliird of the cases tliere was more or 
less of intense fever, but generally the pulse was slow ; some- 
times, after having been slow, it became frequent. The skin 
was hot and the face flushed." 

!N"ow, you must bear in mind that the cases cited by Gin- 
trac were all of great severity, and terminated fatally. You 
must not, therefore, expect to find, in cases of which the lesion 
is very limited, all the symptoms noted by him. Then, too, his 
cases are much more acute in character than the one before 
us, or the others to which I have referred. Four of his cases, 
however, present very great analogies with those to which I 
have called your attention to-day. 

It seems to me, after taking a full consideration of the 
symptoms of this case, and from what we know of others, in 
which post-mortem examinations have been made, that the 
disease in this woman is really basilar meningitis, and, acting 
upon that supposition, I will treat her for that affection. 

As bearing upon the treatment, inquiry should always be 
made relative to the causation, for one of the first things to be 
done in the management of every disease is to remove or coun- 
teract the cause. It is astonishing to find how many of these 
cases are connected either directly or indirectly with a syphi- 
litic taint. As far as my own experience extends, the great 
majority of my patients affected with the disease in question 
acknowledged the preexistence of syphilis ; and, even when they 
failed to do so, in a large proportion of the remaining cases there 
was evidence upon which to found a reasonable suspicion that 
syphilis was at the bottom of the cerebral affection. 

In the present case I have not, after careful inquiry and 
examination, any proof that the woman has ever either directly 
or indirectly been subjected to the action of the syphilitic 
poison, and yet I cannot help thinking that this disease owes 
its existence to the influence of that virus. At any rate you 
will remember that I have frequently inculcated upon you a 
therapeutical principle applicable to the treatment of all ob- 



CHRONIC BASILAK MEmNaiTIS. 179 

scure brain-affections, and tliat is, wlien in donbt, give iodide 
of potassium, and give it largely. I have come to tlie adop- 
tion of this idea not from guess-work, but from the results of 
actual experience, a great deal of which has been brought here 
before you at these clinics. You will, doubtless, recall sev- 
eral quite recent cases in which the symptoms of severe cere- 
bral lesion were unmistakable, and in which complete recov- 
ery ensued upon the administration of large doses of the iodide 
of potassium. I am inclined to think that most of these were 
cases of meningitis of circumscribed extent, and involving 
either the basilar or convex surface of the brain. Whether 
they were or not, the iodide of potassium cured them, and that, 
after all, is the principal point. 

You know, too, how I prefer to give the iodide of potassium 
in these cases. A saturated solution of the salt in water con- 
tains about a grain to the drop. Starting with say five drops 
of such solution given three times a day, I give the next day six 
drops, three times, the next day seven, and so on, increasing a 
drop for the doses of each day, until the patient takes as much 
as thirty or fifty drops to the dose. By this method of ad- 
ministration the system is kept fully under the iufiuence of 
the medicine, and the maximum of the curative effect is pro- 
duced. 

Last year this woman was cured by this plan of treatment, 
and we have every reason to hope that a like degree of suc- 
cess will follow now. 

As regards adjunct treatment, there is nothing which is 
specially indicated in the case before us. Sometimes iron and 
the bitter tonics are proper, and the hygiene should always 
be carefully looked after. Local treatment of any kind is 
rarely beneficial ; and cauterization and blistering are espe- 
cially to be condemned, as they only add to the distress of the 
patient, without in the slightest degree arresting the progress 
of the disease. One point I must not forget, and that is, that 
excessive mental exertion should always be avoided. Indeed, 
the less there is of this the better. 

The patient has a sore brain, and it is no more sensible to 
use it than it would be for her to walk from here to the Bat- 
tery on a sore leg. 



180 CLINICAL LECTURES. 

LECTUEE XY. 

CEEEBEAL CONGESTIOK. 

Havikg already considered many of tlie grave and compli- 
cated diseases of the nervous system, I will now invite your 
attention to an affection which is of vast importance, not only 
as the initial stage of some of the most serious diseases of the 
brain, but also as the avant-courrier of several of those in- 
stances of apparently causeless insanity which so often occur 
in our midst, and shock the community by their great sudden- 
ness, but which nevertheless reveal, on close inspection, well- 
marked symptoms of cerebral disease. In its medico-legal as- 
pect, therefore, cerebral congestion may well claim our most 
earnest attention, but to this branch of the subject it is not 
my intention, at the present time, to refer, as I have on a pre- 
vious occasion given my views at some length on its causative 
relation to insanity, in a memoir^ which I had the honor of 
reading before the Medico-Legal Society of this city, May 13, 
1870. 

By cerebral congestion we mean that condition in which 
the amount of blood in the brain is increased either absolutely 
or relatively. It is of two kinds, namely, the active and the 
passive, which are characterized by different modes of origin 
and different symptoms. In the former there is an increase 
in the quantity of arterial blood circulating in the vessels of the 
brain, whereas in the latter there is an augmented amount of 
venous blood in the cerebral vessels. In some rare instances, 
however, we find that both these conditions coexist in the 
same individual. 

Now, a state of moderate cerebral congestion may exist for 
weeks or months without passing into one of the fully-devel- 
oped forms, yet, upon the addition of a slight exciting cause, 
it may terminate in — 1. An attack resembling apoplexy ; 2. 

* "A Medico-Legal Study of the Case of Daniel McFarlaud," in the 
JouEis^AL OF Psychological Medicine for July, 1870, also published sepa- 
rately by D. Appleton & Co., New York, 1870. 



CEREBEAL CON^GESTIO]^-. 181 

Epileptiform conynlsions ; 3. Inflammation of the brain or its 
membranes ; 4. Mania. From the character of its initial 
symptoms we cannot, therefore, safely predict which one ot 
these forms will be developed, although we can, in most cases, 
by appropriate remedial measures, prevent their occurrence, 
if the patient be observed at a sufficiently early period. 

The most prominent early symptom of cerebral congestion is 
undoubtedly wakefulness, which is due to an excessive increase 
of the amount of blood circulating in the cerebral vessels, so 
that these organs in time become over-distended, and lose their 
contractility from the relaxation of their muscular fibres. To 
be sure, all cerebral action is attended with a certain amount 
of hyperemia, and is within certain limits perfectly normal ; 
but, if these limits be exceeded, and the muscular coats of the 
arterioles are so impaired that the quantity of blood in the 
brain cannot be diminished by their contraction, we have a 
condition of cerebral congestion which is abnormal, and the 
result is loss of sleep, for, as I will now tell you, sleep cannot 
take place without a contraction of the cerebral vessels — an 
action which is accompanied by a diminution in the quantity 
of blood in the brain. 

There is, however, a condition which is often confounded 
with sleep, but which nevertheless differs from it in many es- 
sential respects. And this is stupor. On comparing together 
these two states, the points of difference will be very apparent 
to you : 

1. Sleep is a necessity of life, while stupor never occurs in 
the healthy individual. 2. In healthy sleep a person is easily 
awakened, while it is almost impossible to arouse him from a 
condition of stupor. 3. In sleep the mind may be active ; in 
stupor it is, as it were, dead. 4. Pressure upon the brain, in- 
tense congestion of its vessels, the circulation of poisoned blood 
through its substance, cause stupor, but do not produce sleep. 
In order to induce the latter, it is necess^^ry that the amount 
of blood in the brain should be diminished in quantity. This 
fact has been clearly demonstrated by experimentation, by 
disease or injury, and by means of the" ophthalmoscope. If, 
then, a diminished amount of blood in the brain is the necessi- 
ty for healthy sleep, it would seem to follow logically that an 



182 CLINICAL LECTUEES. 

increased quantity of this fluid in the cerebral vessels would 
produce wakefulness, and this fact is as susceptible of proof as 
that of the opposite condition. 

Before, however, making any extended remarks upon this 
subject, I wish to call your attention to the following history, 
which very aptly illustrates some of the leading features of 
cerebral congestion in one of its different phases, and then I 
will proceed to examine the more obvious symptoms and causes 
of this affection : 

Case I. Active Cerebral Congestion. — " J. Y. is thirty 
years of age, was born in ITew York, and is a school-master by 
occupation, and unmarried. 

" He says that he has always been very healthy, and has 
never suffered from any disease excepting intermittent fever, 
which he had quite severely about two years ago. His father 
and mother are both living, and are, at the present time, in 
good health. His sister died of consumption, and his brother 
has at times suffered severely from neuralgia, which was un- 
doubtedly of malarial origin. 

'' Some three years ago, he commenced the study of the 
law, which he pursued too diligently when not occupied 
with the duties of his school. In the (jourse of time, he 
perceived that his health began to be impaired, but necessity 
required him to attend to his school ; at the same time he was 
reluctant to give up his legal studies. He continued to over- 
work his brain, until he found that he could not sleep more 
than three or four hours during the night. On arising in the 
morning, he felt more fatigued than when he had retired to 
rest the night before. He soon discovered that he could not 
fix his attention with any degree of fixedness to the subject of 
which he was reading, for his mind would wander from it to 
other matters which had no connection with the one before 
him. , 

" In fact, as his disease advanced, he was unable to 
withstand any degree of exertion, either physical or intel- 
lectual. His bowels became costive, his tongue coated, and 
his digestion impaired. He had headache, vertigo, and at 
times noises in his ears. His memory began to fail, and he 



CEREBEAL COISTGESTIOIS". 183 

became so fretful and peevish that he was continually finding 
fault with his scholars, who attributed his ill-nature to the in- 
fluence of liquor, as they could assign no other cause. 

" He continued in this state for some time, the symptoms 
being either aggravated or lessened, according to the emotions 
or thoughts of the patient, his habits or occupation. At last 
he became so wretched that he felt compelled to get medical 
advice, and came to the ]N"ew York State Hospital for Diseases 
of the E"ervous System, where he was examined, and his con- 
dition was found to be as follows : 

"He complained of a dull headache, accompanied with a 
feeling of fullness or distention in the frontal region. There 
were vertigo and noises in his ears, which were increased in 
severity whenever he assumed the recumbent position. There 
were dark specks floating before his eyes, and his hearing was 
morbidly acute, so much so that an ordinary sound would 
cause him mucli discomfort. To obviate this, he had filled his 
ears with cotton. His head was hot, his face was flushed, and 
his eyes were glassy and suffused. The pupils were contract- 
ed and intolerant of light. He still experienced numbness 
and a sensation of tingling in the tips of the fingers of both 
hands. He was easily fatigued upon the slightest exertion, 
either mental or physical. He was very irritable and ex- 
citable, his whole emotional system being very easily aroused 
and in a state of continual erethism. His memory was far 
from being active, and at times his ideas were more or less 
confused. He was troubled with dreams of an unpleasant 
character, which would cause him to dread going to bed, but 
these were not the result of intemperance, for this gentleman 
was exceedingly temperate in all his habits, especially in the 
use of alcoholic liquors. He had illusions and hallucinations 
of both sight and hearing, but he had no delusions. He real- 
ized his condition, said he knew he was sick, and was very de- 
sirious of being cured. It seemed impossible for him to obtain 
a reasonable amount of refreshing sleep, for the greater part 
of the night was passed in pacing his chamber, and if he went 
to bed he would soon arise, dress himself, and seek the open 
air. His pulse was about 90 and full, but not very strong. 
His bowels were costive, but not as much so as they had been. 



1S4 CLINICAL LECTUEE^. 

His urine was examined both cliemicallj and niicroscopicallj, 
and was found to contain an abundance of the urates and alka- 
line phosphates. His heart and lungs were in a healthy con- 
dition. Examination of the retinal vessels, by means of the 
ophthalmoscope, showed the arterioles not only to be unusu- 
ally large, numerous, and tortuous, but it also revealed the 
fact that the optic disk was very much injected, and that the 
choroid was of a very red hue, while the veins were in a near- 
ly normal condition. 

" He was instructed to leave off all mental exertion, to 
take a hot bath every night before retiring, and to sleep in a 
chair, so as to avoid the recumbent position. In addition to 
this he has taken thirty grains of the bromide of calcium four 
times a day well diluted in water, which had the effect of in- 
ducing sleep after he had continued its use for four days. At 
the end of a week the amount of bromide was diminished to 
thirty grains three times a day, and he felt so much better that 
he was told that he could read the papers and light literature 
so as to occupy his mind. In two weeks he was still more im- 
proved, and the bromide was again diminished to sixty grains 
a day. The constant galvanic current has also been applied 
to his head regularly every other day, commencing with ten 
cells, and gradually increasing to fifteen." 

This patient is a very good typical illustration of the pre- 
monitory or first stage of active cerebral congestion ; for you 
will observe that, although the disease has lasted some time, 
nevertheless it has not as yet passed to the apoplectic, the epi- 
leptic, the inflammatory, or the maniacal variety. 

You know, from what has been said, that the symptom 
al)Ove all others that first attracts the attention of the patient 
in cerebral congestion is wakefulness, and this condition not 
only indicates a morbid activity of the brain, but it is of it- 
self a positive sign of cerebral hypersemia, so that, when you 
meet with a patient who is unable to sleep, you may be quite 
sure that the amount of blood in the cerebral vessels is in- 
creased in quantity. There soon follows a degree of mental 
and physical irritability which the patient is unable to con- 
trol. He cannot fix his attention upon any subject which re- 



CEEEBEAL COIS'GESTIOK 185 

quires much tliouglit, and in some extreme cases his ideas be- 
come so confused that he has erroneous conceptions of even 
simple things. It is impossible for him to so concentrate his 
mind as to attend to his daily duties, if these are at all com- 
plex in character. His nervous system is in such a condition 
that he cannot sleep, although at times he feels weary, but he 
is obliged to seek the open air or pace his chamber until, com- 
pletely exhausted, he can obtain a little rest. His sleep is often 
disturbed by unpleasant dreams, and when he arises in the 
morning he feels weary and unrefreshed. In a short time his 
memory, in regard to recent events, becomes impaired, and 
this is especially noticeable in regard to the names of persons 
and places. There is also a proclivity to substitute words hav- 
ing a similar sound when pronounced, or appearance when 
written. His ideas become confused, his judgment is weak, 
and he lacks the ability to so direct his will as to follow any 
definite course of conduct. Illusions and hallucinations soon 
make their appearance, and they are very commonly present, 
those of sight and hearing being, in my experience, those most 
often met with. Delusions may also exist, but they are mere- 
ly false conceptions, which the patient is able to correct by 
means of his intellect, and are never fixed. 

Besides the changes in conduct and disposition, which 
become more marked as the disease progresses, we find that 
the combative proclivities of the patient are easily aroused ; 
that he magnifies the every-day trifles of life, and that his 
whole emotional system is more or less involved. 

Together with these symptoms, there is pain in the head, 
generally of a dull, aching character, accompanied with a 
feeling of heat, fullness, or distention ; there is vertigo, which 
is especially increased whenever the patient assumes the re- 
cumbent position, or leans forward so as to obstruct the 
abdominal aorta. The face is flushed, and there is a fullness 
of the vessels of the head and neck, as may be seen in the 
abnormal throbbing of the carotid and temporal arteries. 
There are noises in the ears, such as ringing, whistling, sing- 
ing, and the like ; or these may be of a more disagreeable 
character. Hallucinations are generally the effect of cerebral 
disturbance, either as regards the quantity or quality of the 



186 CLERICAL LECTUEES. 

blood circulating througli the cerebral vessels, and bence be- 
come an important factor in the diagnosis of cerebral disease. 
There are specks before the eyes, bright flashes of light, and 
other phenomena of an exalted condition of the \isual appara- 
tus. The pupils are always contracted and intolerant of light. 
The conjunctivae are suffused, and the vessels of this mem- 
brane are distinctly visible in many cases where, in health, 
none would be discerned. The eyes have a wild, glassy ap- 
pearance, and frequently motion of the eyeballs is painful. 
Headache is very commonly present, and is in some cases the 
prominent symptom. There is also involuntary twitching 
of the muscles of the face, or of the muscles of other parts of 
the body. Loud noises are frequently productive of much 
discomfort to the patient, owing to the over-excitation of the 
auditory nerve, which is now in a state of morbid activity. 
In many instances I have observed bleeding from the nose, 
which of itself points to a hypersemia of the vessels of the 
head. 

We also notice that there is a slight impairment of speech, 
which is more apparent at one time than another, and is par- 
ticularly to be observed in the pronunciation of those words 
which require the perfect coordination of the muscles of the 
tongue and of the lips, such as words abounding in labials 
and linguals. 

Nevertheless, there is no paralysis of the face ; and the 
tongue, when protruded, does not deviate to either side, even 
when there is well-marked paresis in the arm and leg on one 
side of the body. But this paresis is not always confined to 
one-half of the body, although this is undoubtedly the general 
rule. Not only is the power of motion affected, but there also 
exist perversions of sensation, which are characterized by for- 
mication, numbness, a feeling as though the limb were asleep, 
or pins and needles were sticking in it, or as though water 
were trickling over it. 

These abnormal sensations may be general, but they are 
usually localized in some particular part of the face or the ex- 
tremities. The bowels are costive, the urine is scanty, high- 
colored, and abounding in an excess of the urates and phos- 
phates. The appetite is either lessened or abolished, while 



CEEEBEAL CONGESTION. 187 

the digestion is imperfect. Tlie pulse is at first full and slow, 
but, after a while, it is increased in frequency, and there is 
often present palpitation of the heart upon slight emotional 
excitement, which indicates a weak and excitable condition ot 
the nervons system. The skin is either dry and harsh, or else 
it is bathed in perspiration. Examination, by means of the 
thermometer, shows an increase in the temperature of the 
head, while the sesthesiometer reveals the existence of an 
aberration, either of increase or diminntion, in the tactile sen- 
sibility. The use of the ophthalmoscope will undoubtedly as- 
sist us materially in corroborating the fact whether the patient 
be suffering from cerebral congestion or not ; and it is, there- 
fore, of great assistance in arriving at a proper conclusion. It 
we find that the retinal vessels are increased in number, diam- 
eter, and tortuosity, that the optic disk is congested, and that 
the choroid is unusually red in color, we can safely predict 
that the patient is suffering from cerebral congestion ; but, if 
there be added the symptoms that I have already described, 
we can say to a certainty that this disease exists. 

In all instances, of course, the symptoms are not as well 
marked as in the case before us, or as in the description which 
I have given. Ordinarily, the patient is not confined to his 
bed, but is up and about, although he is not usually in a fit 
condition to attend to the more complicated duties of his busi- 
ness with any degree of efiiciency. 

The next case which I shall bring before you to-day differs 
in some important particulars from the one which I have just 
considered, but I will first read to you the history, so that you 
may then be the better prepared to comprehend the distinc- 
tion which I wish to draw between it and that of active cere- 
bral congestion. 

Case II. Passive Cerebral Congestion. — " J. T. is forty- 
five years of age ; is single ; was born in Ireland, and is a 
stone-mason by occupation. 

"He has a tine physical constitution, and has always had 
remarkably good health. There is no hereditary predisposi- 
tion to diseases of the nervous system in his family, so far as 
he is aware. He is temperate in his habits, and has been 



188 CLmiCAL LECTUEES. 

SO all Ills life. He never remembers to have suffered from 
any form of disease whatsoever, excepting nocturnal emissions, 
which for many years past have occurred as often as three or 
four times a week, and at night during voluptuous dreams, 
and, as he thinks, are the cause of his present trouble. About 
Christmas, during the year 1867, he went to bed as usual, 
and soon fell asleep, but, contrary to his ordinary custom, he 
awoke in a short time, and was able to obtain little or no 
rest during the remainder of the night. Having always been 
accustomed to sleep uninterruptedly for at least seven hours 
every night, he retired the following evening at his usual 
hour, and again found no better success than on the previous 
occasion. From this period up to the time that he first came 
under our observation this abnormal condition has lasted, - 
which is now about four years, although varying in degree 
under the infiuence of treatment; nevertheless he has sel- 
dom, during the whole of this long lapse of time, enjoyed 
a whole night's unbroken slumber. "When he does obtain 
three or four consecutive hours of undisturbed sleep, he con- 
siders that he is doing well. One fact, however, is to be 
borne in mind, and that is, although this patient imagines 
that he sleeps only two or three hours out of the twenty-four, 
yet he undoubtedly underrates that amount, as most persons 
do who are unconscious, and probably obtains more rest than 
he really imagines. He has had no headache, no vertigo, no 
pain in the head, no illusions nor hallucinations ; in fact, he 
has suffered from none of the many well-marked symptoms of 
cerebral congestion, if we except the persistent wakefulness, 
which in this case seems to be the prominent and prevailing 
symptom. 

" Besides this morbid condition of wakefulness, he experi- 
ences at times a tendency to somnolence, although he is 
unable to sleep ; and, when he passes into this condition, he 
suffers from dreams which are perfectly hideous in character, 
and which seem to affect him as much as though they were 
real. Before coming under our observation, he had been in 
the habit of drinking a pint of beer every night before re- 
tiring, and he seems to have realized some benefit from this 
agent, as it afforded him for some time about three or four 



CEREBEAL CONGESTION. 189 

consecutive hours' undisturbed rest, and then he would awake, 
and he was able to obtain little or no sleep during the re- 
mainder of that night, nor even during the next day, although 
he felt as if he would fall asleep at any moment. 

^' Such had been his condition prior to his coming under 
our care, when he was examined, and the following symptoms 
were noticed : 

" The appearance of the patient, although not peculiarly 
striking on inspection, is quite perceptible in some respects. 
There is a well-marked redness of the face, which partakes of 
a livid hue. 

'' There are a prominence and a fullness of the veins of the 
head, which are quite conspicuous. The eyes are dull and 
glassy in appearance, while the pupils are contracted ; but 
the conjunctivae are not injected. He has no headache at the 
present time, no vertigo, no flashes of light before the eyes, no 
ringings in the ears, and no delusions. His mind is clear, and 
he attends regularly to his business every day ; yet he does 
not appear to grasp subjects presented to him with that readi- 
ness of comprehension which characterizes most persons of his 
degree of intelligence. His memory is very good, and his 
emotional system is by no means either excitable or depressed. 
All his bodily functions appear to be performed normally, and 
he is very well nourished, although he says that he has lost 
much flesh. His bowels are regular, his tongue is clean, and 
his appetite is not materially impaired. He is still troubled 
with unpleasant dreams, and, although he feels sleepy nearly 
all the time, he is unable to obtain more than three or four 
hours' undisturbed rest during the night, while it is quite im- 
possible for him to sleep during the day. He also complains 
of a feeling of lassitude, which is more marked after his day's 
work is done than in the morning. His heart and lungs are 
healthy. His urine is deficient in none of its ingredients, but 
the alkaline phosphates are in excess. Examination of the 
eyes by means of the ophthalmoscope revealed the fact that 
the arterioles and veinules were increased in size. There was 
peripapillary infiltration in both eyes. The retinal veinules 
were tortuous and immensely dilated, forming large sacs, or 
pouches, which at first appeared as though clots of blood had 



190 CLIIflCAL LECTUEES. 

been effused ; but this was not tbe case. He does not at the 
present time suffer from nocturnal emissions. His eyesight is 
good. I The retinae are intolerant of light, as is shown by the 
continued contraction of the pupils. 

" He has been subjected to a great variety of remedial 
agents, as will be seen from the following list of some of the 
many which he has taken, viz. : bromide of potassium, hy- 
drate of chloral, cyanide of potassium, humulus lupulus, tinct- 
ure of valerian, tincture of hyoscyamus, phosphide of zinc, 
oxide of zinc, extract of nux-vomica, and beer. He has also 
had various remedies applied to his spine. 

" From this category he has only experienced benefit from 
the bromide of potassium, the hydrate of chloral, and the 
potation of beer. But these in time lost their efficacy, and 
were soon relinquished to give place to others. 

" The treatment recommended in this case was the passage 
of the primary galvanic current daily through the head, so as 
to act upon the vessels of the brain, with a pint of ale an hour 
before going to bed, and thirty grains of the bromide of lithium, 
thrice daily, well diluted in water. At times whisky has been 
substituted for the ale. 

" After the lapse of two months the patient could sleep 
five or six consecutive hours, and the dreams which had afford- 
ed him so much discomfort were only occasionally present, and 
then lasted a very short time. He gained strength and fiesh 
very fast, and, although not cured, the vessels of the retinae 
had at this period perceptibly diminished in size." 

Instead of the well-marked symptoms which existed in the 
previous case, we find in the patient before us only a few 
prominent features of cerebral disturbance ; but yet these are 
sufficiently distinct to enable us to diagnosticate it from that 
of active cerebral congestion. I have already drawn your 
attention to the distinction between healthy sleep and stupor. 
Now, in passive cerebral congestion the vessels of the venous 
system are overladen with blood, owing to some interference 
in the return-circulation, and, as a consequence, the amount 
of venous blood in the brain becomes augmented. This condi- 
tion is manifested by nearly the same phenomena in many 



CEEEBEAL CONGESTIO^nT. 191 

cases like those we Lave already observed in the other patient ; 
but, instead of the morbid wakefuhiess, we find in the passive 
form a tendency to stupor which is never to be found in the 
active variety, while the character of the dreams in the patient 
before ns is of that description which we find in those who 
sufier from the passive form of the disease. You may, how- 
ever, have nearly all the symptoms which I have already 
described as existing in active cerebral congestion, in passive 
cerebral congestion, but, so far as my experience goes, they 
are never of a very prominent character, and, when they do 
exist, they are generally fewer in number, and only slightly 
marked. In the present instance, for example, we have a 
condition of wakefulness with a tendency to stupor, which is 
the prevailing feature of this patient's disease, and,:besides, 
he suffers from the most frightful dreams. These are indica- 
tions that the amount of venous blood in the brain is increased 
in quantity, for, the mere fact of dreaming points to cerebral 
hypersemia ; and, when we also consider that in the active va- 
riety of cerebral congestion there is no tendency to stupor, but, 
on the contrary, continual wakefulness, we are in a position to 
prove, even from the few symptoms which this patient presents, 
that he is snfiering from passive cerebral congestion. And 
assurance is made doubly sure from the light which we derive 
through the means of the ophthalmoscope, which corroborates 
by ocular demonstration the result which we have already 
arrived at. 

You will also observe that there are no headache, no ver- 
tigo, no illusions, no hallucinations, and no delusions, though 
all these symptoms are occasionally present. The patient's 
mind is not active, but he is able to attend to his business 
without any trouble, while there seems to exist no percep- 
tible disturbance in his emotions, for he is neither irritable, 
peevish, nor fretful, but, on the contrary, he seems to be in 
a pleasant frame of mind. Without going into unnecessary 
details, I will call your attention for a moment to the ex- 
cess of phosphates, which was found in the urine of both the 
patients which I have shown you here to-day. You know 
that the brain, like all the other organs in the body, is con- 
stantly undergoing destruction of its tissue, and that increased 



192 CLINICAL LECTURES. 

action on its part accelerates the metamorphosis of nervous 
tissue which abounds in phosphorus, and, as a consequence, 
an increased amount of the alkaline phosphates in the urine is 
the direct result of an overworked brain. 

Then, again, you perceive that the bodily functions of this 
patient are normally performed. His bowels are regular, his 
skin is moist and cool, his tongue is clean, his digestion ap- 
pears to be good, his pulse is about 70, although a little 
weak, and his aspect has very much improved since I last saw 
him some weeks ago. He has been under treatment about 
two months, and he finds that he can now sleep the greater 
part of the night without being disturbed by those frightful 
dreams which annoyed him so much, when I first saw him. 
He has also improved in flesh, and he says that he feels much 
stronger and more inclined to work than he did a short time 
ago. 

- But he has not yet recovered, for even now he sleeps only 
about five hours, whereas he has been in the habit of getting 
seven or eight. But, if he continues the treatment, he will be 
cured, and there is now no danger of the affection passing into 
the apoplectic, the epileptic, or the maniacal form, with due 
care on his part ; for you know that the passive as well as the 
active variety of cerebral congestion often terminates in this 
way, although the former is much more liable to pass into one 
of the fully-developed forms than the latter. 

There is another distinction to be observed, which it may 
also be well for you to bear in mind, and that is that the pas- 
sive form of cerebral congestion is of more frequent occurrence 
in old persons than the active, and this is undoubtedly ac- 
counted for by the fact that the vital power is less in the aged 
than in those who are in the prime of life. Without dwelling 
any longer upon the premonitory form of cerebral congestion, 
I will pass to the consideration of some of its fully-developed 
varieties. I will first, however, read you the following history, 
which is a very good example of the disease in a more ad- 
vanced stage : 

Case III. Apoplectic Cerebral Congestion of the Active 
Form. — "A. C, who is thirty years of age, was born in the 
United States, is single, and a lawyer by profession. 



CEREBRAL COI^aESTION. 193 

" He possesses a very excitable and nervous temperament, 
and is very easily aroused to anger upon the most trivial oc- 
currences, but nevertheless he had attained great reputation at 
the bar for a person of his age. He has always been very ec- 
centric in his ideas and in his actions, but, notwithstanding 
this, he has devoted himself assiduously to his profession, hav- 
ing been an excellent student all his life. He has a rather 
weak constitution, and of late years has still more impaired 
his health by excesses of all kinds. He has been in the habit 
of sitting up very late, especially when he became interested 
in any important case, and, as his mental energies became weak- 
ened for want of rest, he would arouse them temporarily into 
activity by an increase in the quantity of brandy and strong to- 
bacco used. Some years ago he had a severe attack of typhoid 
fever, which left him in a deplorable condition, and from the 
effects of which he has never fully recovered. Many members 
of his family have been and are insane. He has, for some time 
past, had the most exalted ideas of his own powers of intellect, 
and of his own importance, but these had not as yet obtained 
such a mastery over his mind but that he could be reasoned 
out of them quite readily by well-directed argumentation. 
^Nevertheless, they showed very plainly that his mind was not 
in a healthy condition. Some three years ago he applied him 
self more assiduously to his professional duties than usual, still 
leading a very irregular life, and as a consequence he became 
very much reduced in health. He lost flesh, grew pale and 
thin, and could not sleep at night. He was troubled with un- 
pleasant dreams, and when he awoke in the morning he felt 
so weary and depressed that he used to take three or four 
drinks of brandy before he could get an appetite for breakfast, 
and even then he ate very little. After breakfast he would 
commence to smoke strong cigars, which he indulged in almost 
uninterruptedly until dinner, and which he would resume as 
soon as that meal was finished, and continue until he retired 
at night. 

" He soon began to complain of vertigo, a dull, heavy feel- 
ing in the forehead, and he had illusions of sight. He was de- 
spondent, and unable at this time to attend to his professional 

13 



19-i CLINICAL LECTUEES. 

duties in a satisfactory manner, yet he still tried to continue 
them to the best of his ability. 

" About this period he received from home intelligence of 
a highly-exciting character, but he made no mention of the 
fact to any one, but went directly from his office to his resi- 
dence, where he lighted the gas, and in about an hour was 
found lying on the floor in an unconscious condition. 
'' At this period he was in the following state : 
" He was unconscious to all appearance, but not to such 
an extreme degree but that he could be partially aroused. 
His face was flushed, but there was no distortion. A candle 
held before his eyes caused him to close his eyelids. There 
was loss of power in the arm and leg on the right side ; the 
temperature of the limb was not, however, diminished in de- 
gree, and on tickling the sole of his right foot it was im- 
mediately withdrawn. His respiration was slow, about 14 
per minute, and a little irregular. His pulse was about 60, 
full and hard. There was no stertor, nor puffing out of the 
cheeks, although the respiration was somewhat noisy. When 
he was asked how he felt, he answered ' Yes,' and whatever 
questions were put to him he invariably responded to by the 
same answer. In the course of an hour, the stupor began to 
pass away, and he was then examined more minutely. He 
walked to his lounge with assistance, for the right side of his 
body was still weak. His mind was as yet very much con- 
fused, and he did not seem to realize where he was nor what 
had happened. He, however, in a short time recognized his 
friends, and, during the ophthalmoscopic examination, he said 
that ' he could not hold his eye steady because the light pained 
him.' His pupils were very much contracted and exceeding- 
ly sensitive to light. The retinal arterioles were immensely 
dilated, while the veinules were small. The former were also 
very tortuous, and their pulsation was quite apparent. The 
choroids were excessively red in color. Tactile sensibility in 
the right arm and leg seemed to be increased rather than di- 
minished. The patient could move his arm and leg, which 
were quite warm and supple, but not with any great degree 
of facility. The tongue did not deviate when protruded. The 
pulse and respiration had increased somewhat in frequency. 



CEEEBEAL COIS-GESTIO]^. 195 

There liad been no relaxation of tlie sphincters of either the 
bhidder or the rectum during the comatose state. The pa- 
tient, as soon as he was put in bed, began to cry, but even 
during this emotional excitement no paresis of the muscles of 
the face was observed, although it was diligently sought for. 

" His head was still hot, and his bowels were costive. His 
tongue was covered w^ith a thick brown fur, and his breath 
was fetid. His eyes were bloodshot, and the vessels of the 
face, neck, and temples, throbbed with abnormal force. His 
digestion had been for some time impaired, and his appetite 
poor. The family also informed us that this young gentleman 
had been in the habit of using opium, but to what extent they 
were unable to state. 

" He was ordered to be confined to his bed, and to be fed 
regularly with strong beef-tea. Ice was applied to his head 
by means of India-rubber bags, and thirty grains of the bro- 
mide of potassium were ordered to be taken every four hours 
until sleep was produced. "No cathartics were administered, 
as the bromide was expected to act sufficiently upon the 
alimentary canal to cause an evacuation of the bowels. Af- 
ter the lapse of twelve hours, the patient fell asleep and 
slept soundly for about three hours ; he then awoke and had 
an evacuation. The next day his tongue looked much 
clearer, his head was less hot,j|^nd his appetite, although 
poor, allowed him to take quite an amount of beef-tea. The 
quantity of bromide was now diminished to one hundred and 
twenty grains daily, and, a*s he gradually grew better, and 
slept longer, more nutritious food and a less amount of bro- 
mide were given. At the end of three weeks he was directed 
to go to the country, and as his sleep had become more regu- 
lar, and his pulse was rather weak, he was advised to take 
phosphorus and iron as tonics, still, however, taking sixty 
grains of the bromide daily, well diluted in water. The pare- 
sis of the right arm and leg had, at this time, entirely disap- 
peared, although he felt some weakness in the lower extremi- 
ties, but this was undoubtedly due to the influence of the 
bromine. In the course of two months he had improved so 
much that he resumed the practice of law, but he was admon- 
ished to avoid, as much as possible, all those causes which had 



196 CLINICAL LECTURES. 

been influential in developing the attack, such, as intemperate 
habits and undue mental strain, and was told that, if these 
were continued, he would suffer a relapse which might be 
more serious in its consequences." 

In the present instance we have a certain set of symptoms 
preceding the apoplectic stage of cerebral congestion, and this 
is generally the case, so far as my experience extends. But 
occasionally the attack comes on suddenly without any very 
obvious cerebral symptoms, although careful inquiry will 
generally reveal their existence. In the case of an old gentle- 
man of this city, who was under my charge for cerebral 
haemorrhage, there had been three or four attacks of loss of 
consciousness accompanied with paralysis of the right side. 
He would, for instance, be walking in the street, when sud- 
denly he would be attacked with a shai^ pain in his head ; 
there would be specks floating before his eyes, noises in his 
ears, and then he would feel dizzy, his eyesight would be- 
come dim ; he would stagger, lose consciousness, and fall to 
the ground. In a few moments he would recover his senses, 
but for some hours afterward there were paresis of the right 
arm and leg, and confusion of ideas. Now, if at this time 
proper treatment had been employed, the effusion of a clot of 
blood would not have taken place in this man's brain. The 
extreme congestion was merely the first stage toward a more 
serious lesion of the brain, for, as subsequently happened, 
owing to the weakening of the cerebral vessels on the left 
side, blood was eflused during one of these attacks, and the 
patient is now permanently paralyzed on the right side of his 
body. This gentleman had also organic disease of the heart ; 
but, that these attacks were not due to embolism is very mani- 
fest from the fact that there were premonitory symptoms, 
which, however, were of short duration, and there was no apha- 
sia present, although the left side of the brain was involved. 

In the apoplectic variety of this disease, the loss of con- 
sciousness is of short duration, and the loss of intelligence is 
never so complete as in cerebral haemorrhage. The patient, 
although in apparently a deep state of coma, can be aroused 
and made to answer questions in the same manner as a patient 



CEEEBEAL CONGESTION-. 197 

suffering from concussion of the brain. To be sure, tlie power 
of the mind is greatly lessened, but the senses still convey to 
the brain the excitations from without. Thus, a bright light, 
held before the eyes, will cause the patient to close his eye- 
lids. 

The loss of intelligence and of sensibility may exist for a 
few seconds or for hours, as will be seen from the cases which 
I have alluded to to-day. 

The patient before you, you will remember, was uncon- 
scious for nearly two hours, while in the instance of the old 
gentleman, to whom I have just referred, consciousness was 
abolished for only a few seconds, or, at the most, a minute or 
so. The paralysis generally affects all four extremities, al- 
though it is occasionally restricted to a single limb or one-half 
of the body. In the present instance it is limited to the right 
upper and lower extremities. There is no paralysis of the 
face, and this is an important point of distinction between this 
fonii of disease and cerebral haemorrhage, although occasion- 
ally a slight paresis of the face may exist, yet never to the 
game degree as that found in cerebral haemorrhage. It is 
rarely that we find paralysis of the uvulae and soft palate in 
this affection, which, as you know, is so commonly found in 
conditions of profound coma. The power of motion in the 
affected limbs is not abolished, but is merely impaired, for the 
patient can still perform many movements, but not perhaps 
with his accustomed facility, on account of a lack of the re- 
quisite amount of muscular strength. The reflex power is not 
much involved, for the patient still withdraws the limb upon 
the application of an ordinary excitation. 

While in this semi-comatose condition, he replies to ques- 
tions with difficulty and often very indistinctly ; nevertheless, 
the mere fact of his responding at all shows that the sensorium 
is still able to take cognizance of external impressions, although 
very imperfectly. The respiration is generally slow, loud, and 
at times irregular, while the pulse is hard and full. The face 
is usually flushed, but occasionally it is pale. Tactile sensi- 
bility, like the power of motion, may be either increased or 
diminished, but it is never entirely abolished. The tempera- 
ture of the affected limbs seems to be unaffected, and these, 



19S CLmiCAL LECTUEES. 

even when the paralysis is well marked, are warm to the touch, 
and supple. 

The digestive organs likewise may become involved. The 
tongue is coated, the bowels costive, and the skin is either dry 
or moist. The head is usually hot, and the nrine scanty and 
high-colored, or pale and abundant. There is no paralysis of 
the facial muscles, consequently no puffing out of the cheeks 
and lips at each expiration. "When the patient becomes con- 
scious, which in most cases is in a very short time, it will be 
found that the tongue, when protruded, comes out straight. 
"Where the pren^onitory symptoms have existed for some time, 
as in the patient before us, the physical symptoms of dis- 
ordered cerebral action will be much more prominent than 
where this affection is initial, as occasionally happens. As 
soon as the stage of coma has terminated, we find that the 
patient suffers for a considerable period from both mental and 
physical exhaustion, which is the result of the excessive hyper- 
semia to which his brain has been subjected. Perhaps, of all 
the fully-developed forms of the active variety of cerebral con- 
gestion, none is more common than the one before us ; conse- 
quently, when it occurs, we should be on our guard that active 
measures be taken to relieve the over-distended cerebral ves- 
sels as soon as possible, in order to diminish the risk which all 
persons run who are afflicted with this form of the disease, of 
the effusion of serum into the cerebral tissue or its ventricles, 
which speedily produces death as soon as it occurs. 

Having thus called your attention to the principal symp- 
toms in this form of the disease, I now pass to the considera- 
tion of another. 

Case IY. Active JE^j?ileptiG Cerebral Congestion, — " M. L., 
aged thirty-five, was born in Massachusetts, is a merchant by 
occupation, the father of two children, and a resident of this 
city. He is a short, thick-set man, of a highly-susceptible nerv- 
ous temperament, and has suftered quite severely of late years 
from dyspepsia. He is temperate in his habits, and is par- 
tially deaf in his left ear, which is the result of a severe attack 
of scarlet fever which he had in childhood. When about 
twenty-four years of age, he had small-pox, and ever since his 



CEEEBEAL CONGESTIOIT. 199 

convalescence from that disease lie lias suffered more or less at 
times from dyspepsia accompanied witli gastralgia. His father 
died of cerebral haemorrhage some years ago, and his mother 
is now afflicted with Bright's disease of the kidneys. He has 
also a sister who is at present confined in an asylum for the 
insane, where she has been for several years. His brother has 
been subject to violent paroxysms of neuralgia for the last ten 
years, but they would only last for a short period, and then dis- 
appear for a month or so, when they would return with re- 
newed violence upon a very slight exciting cause. 

" About a year ago his wife was attacked with typhoid 
fever, and, as he watched constantly by her bedside day and 
night, he became completely exhausted both mentally and 
physically, but still he contrived to administer to all her 
wants. At the same time he was obliged to superintend a 
large business, which caused him great anxiety, as he had 
entered very heavily into certain speculations which de- 
manded his whole attention, and which he knew very well 
needed his watchful supervision. Finally, however, as his 
wife became worse, his mental condition was such that he 
could not concentrate his mind upon any subject, and he was 
obliged to delegate his business to his partner. He became 
peevish and irritable in the extreme ; he suffered from severe 
headache, vertigo, and loss of appetite. He could not sleep ; 
there were loud noises in his ears, bright flashes of light be- 
fore his eyes, and a feeling of exhaustion which prevented 
him, in a great degree, from attending to the wants of his 
wife. His bowels were constipated, his urine high-colored 
and scanty, his cheeks flushed, and his pulse slow but weak. 
While in this condition, his wife died, and for three nights 
subsequently he did not sleep at all. He took morphine in 
small doses, but it had no effect whatever in producing sleep. 
At this time he learned that his speculations had been unfor- 
tunate, and had involved him very heavily in debt, and that, 
in order to save his good name, it was necessary that he 
should sacrifice all he had. 

" He immediately ordered a carriage, with the intention 
of going to his place of business, to see if the report were true. 
On his arrival there he had a short conversation with his part- 



200 CLINICAL LECTUEES. 

ner, during which he became very much excited. Suddenly 
he turned very pale, said he felt very badly, and then gradu- 
ally sank to the floor. At first his limbs were extended, per- 
fectly rigid, and the fingers tightly drawn into the palms of 
the hands. In a short time, however, the color of his face 
changed to a dusky hue, and he was seized with clonic con- 
vulsions, which continued for about ten minutes, and then 
ceased. After this he passed into a condition of stupor, which 
lasted about half an hour. As soon as he rallied from this 
condition he became delirious, and continued so for several 
hours. From the commencement of the attack until the ces- 
sation of the stupor he was perfectly unconscious. He was 
now seen and examined, and the following points of interest 
were noticed : He was in a highly-delirious state. His eyes 
were bloodshot, glassy, and wild. His face was flushed and 
bathed in perspiration. He was at times incoherent, and he 
had illusions, hallucinations, and delusions, of various kinds, 
which were not fixed, but were constantly changing. His 
pulse was 120, quite weak, and irregular. His tongue was 
covered with a thick brown fur, and had not been bitten. It 
was necessary to restrain him, although not much force was 
required. He was perfectly conscious, and answered ques- 
tions put to him, although at times rather incoherently. The 
bromide of calcium was ordered to be administered to him, in 
thirty-grain doses, well diluted in water, every three hours 
until he slept. The next day the delirium had passed away, 
and he appeared quite rational. As his bowels were costive, 
an aloetic purge was prescribed. At this time he was suf- 
fering from the symptoms of well-marked cerebral congestion 
of the active form, so that the bromide of calcium was con- 
tinued, in thirty-grain doses, three times a day. As his pulse 
was very weak and his digestion very much impaired, he was 
directed to take strong beef-tea and a glass of sherry wine, jpro 
re natd. 

" In the course of four or five days his tongue became 
clean and his appetite improved. He could now sleep soundly 
for five or six hours. He was at this time put upon a highly- 
nutritious diet of beefsteak, milk, and eggs. His bromide 
was not reduced in quantity until the end of two weeks, when 



CEREBRAL COI^GESTION. 201 

he slept very well, and then his daily allowance was sixty 
grains. In addition to the bromide, the primary galvanic 
current was applied regularly every other day to his head 
and sympathetic nerve, in the manner that has already been 
described. As he needed change of scene to repair his shat- 
tered health, he was advised to go to Europe, in addition to 
taking a tonic com^se of treatment, consisting of phosphorus, 
iron, quinine, and strychnia. At the end of six months he 
returned to this city and resumed his business, very greatly 
improved in health. It is now over two years since he first 
came under our observation ; yet, since his return from Eu- 
rope to the present time, he has had no cerebral symptoms 
whatever." 

Before passing to the consideration of the causes and treat- 
ment of cerebral congestion, I wish to make a few brief re- 
marks upon the present case. I have already told you that 
there are two varieties of the epileptic form of cerebral con- 
gestion — the active and the passive — but these do not differ 
from each other in such essential particulars as is observed in 
the apoplectic forms, where the symptoms are markedly at 
variance. The main points of difference between the epilep- 
tic forms I will briefly enumerate, in order to assist you in 
making the distinction. In the passive variety the tongue is 
more commonly bitten. The attack is more often followed by 
paralysis, which is of longer duration than in the active form 
of the disease. There is an increased length of the fit, and 
the stage of stupor is usually more profound, and generally 
lasts a longer time, while the repetition of the fits is by no 
means uncommon. The remaining phenomena, however, in 
these two varieties, are nearly analogous. But I have found, 
in the large number of cases which have fallen under my ob- 
servation, that the epileptic form of passive cerebral conges- 
tion is of more frequent occurrence than that of the active. 
The active form generally occurs in persons who are in the 
prime of life, but it may occur in those well advanced in 
years, and then it is generally dependent upon some organic 
alteration in the brain, of which the epileptiform attack is 
merely the expression, and in these cases we can usually pre- 
dict a fatal termination. 



i:02 CLrNicAL lectures. 

In the case whicli I have just read to you, you see that the 
attack is ushered in by the premonitory symptoms of cerebral 
congestion, and I believe this is generally the rule, although 
the attack, in some instances, takes place with great sudden- 
ness. It will be unnecessary for me, therefore, to dwell upon 
the premonitory symptoms which I have already so fully de- 
scribed, but I will rather call your attention to the attack 
itself, which is characterized by the absence of certain phe- 
nomena which are generally present in true epilepsy. 

Suffice it to say that the patient staggers and falls to the 
ground slowly; that there is never an aura preceding the 
attack, nor is the onset of the paroxysm accompanied with 
that peculiar cry which is so commonly met with in instances 
of true epilepsy ; that the tongue is rarely bitten ; that the 
stage of stupor is neither so long nor so profound as it is in 
true epilepsy ; that the stage of most intense congestion is not 
at the beginning of the attack ; and that in epileptiform cere- 
bral congestion the paroxysm is preceded by the well-recog- 
nized symptoms of the premonitory stage, which are not pres- 
ent in epilepsy. There may be a number of attacks, but it 
must be remembered that this form never takes place during 
sleep, and that the ^paroxysms are generally few in number, 
while in other cases there is a repetition of the attacks. In 
all other respects there is an analogy to epilepsy, which is 
very obvious. Without, however, going into a minute de- 
scription of this case, let us examine some of its phenomena, 
and then we shall be able to contrast them with those found 
in epilepsy, which I shall consider fully in another lecture. 

For some considerable period, you remember, there were, in 
this patient, manifest symptoms of cerebral disorder, which had 
at last arrived at such a degree of intensity that it only needed 
a slight exciting cause to bring on one of the fully-developed 
forms ; and this was not wanting for any length of time, for 
the sudden news of his loss of fortune, together with the death 
of his wife, was sufficient in his state of mind to produce that 
culmination. Prior to his losing consciousness, however, he 
turned very pale, said he felt badly, and then slowly and 
gradually sank to the ground. You observe that there is no 
mention made of an aura, or of the peculiar cry, which were 



CEEEBEAL C0IS-GESTI01S-. 203 

undoubtedly absent, for I liave never met with them in cases 
of this kind. The tonic convulsion was short, as it usually is 
in such cases, and then followed clonic spasms, which, in this 
patient, seem to have been general, although we often lind 
them limited to one side of the body, or to a particular set of 
muscles. He then passed into a state of stupor, which lasted 
half an hour, and which, although long for this form of the 
disease, was neither as profound nor as prolonged as we often 
find in epilepsy. If the patient had been seen either during 
the paroxysm or the subsequent stage of stupor, it would have 
been impossible to have told whether he was suffering from 
true epilepsy or an epileptiform attack of cerebral congestion, 
without we had had more copious information upon the sub- 
ject than those manifestations would themselves furnish. As 
soon as the stage of stupor had abated, the patient passed into 
a state of cerebral activity, which was characterized by illu- 
sions, hallucinations, and delusions, by increased heat of the 
head, flushing of the face, acceleration of the pulse, incoher- 
ence, an excess of motility, and congestion of the vessels of the 
brain, as shown by the active character of his delirium, and 
the loss of sleep. "When asked certain questions, he replied 
quite rationally, although at times he was more or less inco- 
herent ; but, nevertheless, he showed by his ready replies that 
his brain took cognizance of external impressions, and that he 
was therefore conscious of what was said to him, while the 
character of the delusions, which were constantly changing, 
and some of which he was able to describe, could not have 
existed in a state of complete unconsciousness. From this fact 
we are enabled to draw the distinction very clearly, and prove 
that this patient was not laboring under an attack of epileptic 
mania ; for, without loss of consciousness, there is no epileptic 
mania. On the contrary, instead of his mental faculties being 
obscured, they were in a state of undue activity ; when asked 
to protrude his tongue, he did so with readiness ; but there 
was no lesion of its tissue discoverable, which is another factor 
to be taken into consideration in arriving at a proper diagno- 
sis. Although his motility was active, yet he was easily re- 
strained with little or no force, and in this respect we see a 
wide difference from the blind, impulsive fury of the epileptic. 



204 CLINICAL LECTUEES. 

who unconsciously displays his excess of force in outward 
destructive action, which neither argument nor persuasion can 
at all influence. Another point, which it is well to mention 
in this connection, is the hallucinations of hearing in this 
patient. You remember that he was deaf in his left ear, 
but this did not at all affect the character or the inten- 
sity of his false perceptions, which were not derived from 
without, but owed their origin to an increased amount of 
blood in the auditory organs, and which would have existed 
if he had been completely deaf in both ears. The state of 
delirium is occasionally observed in those suffering from the 
present form of cerebral congestion, but its duration is gen- 
erally short, lasting only a few hours or so, as in the present 
instance. After the attack has subsided, the symptoms of 
cerebral congestion still remain and need appropriate treat- 
ment, as has already been described in the history, but which 
I shall speak of more fully when I come to the subject of treat- 
ment. If, however, there be a succession of attacks, the mind 
and physical constitution of the patient are usually impaired 
in the same manner as in those who are subject to frequent 
attacks of epilepsy. The advantages of early treatment are 
aptly illustrated by the success which has followed in this case, 
and which has undoubtedly been the means of saving this gen- 
tleman from subsequent attacks, and from more serious organic 
changes which would have been sure to follow if his cerebral 
vessels had not been relieved of their excessive amount of 
blood. 

The causes of cerebral congestion are numerous, and may 
properly be divided into two categories, namely, the predis- 
posing and the exciting. 

The former are to be found in the individual as an inher- 
ent part of his organization, and are, first, sex — for the disease 
is more common in males than in females. IS^ext, age — the 
affection being more common in middle life and old persons. 
Then we have organic diseases of the heart, which may either 
increase the amount of the blood sent to the head, as in cases 
of hypertrophy, or impede its return, as we find in valvular 
disease and dilatation of the right side of that organ. And, 
lastly, we have shortness of the neck, though this point has not 
as yet been definitely settled. 



CEREBRAL CONGESTION 205 

Amons: the excitino- causes are those which induce the 
active form of the disease by increasing the amount of arterial 
blood in the brain, and those which produce the passive form 
of the disease by obstructing the return of venous blood to the 
right side of the heart, so as to induce a sluggishness of the 
venous circulation. 

Of these, the most common are bad hygienic influences, 
such as the inhalation of a noxious atmosphere, exposure to in- 
tense heat, cold, or dampness, a poor quality of food, sudden 
and excessive physical exercise, the ingestion of a large quan- 
tity of food, disease of the heart, a dependent position of the 
head, blows upon the head, constriction of the vessels of the 
neck from any cause, constipation of the bowels, rapid eating, 
the direct rays of the sun, certain general and local diseases, 
such as disorders of menstruation, erysipelas, the stojDpage of 
a customary flux, fevers, embolism, thrombosis, and the like ; 
alcohol, opium, quinine, strychnia, belladonna, hashish, and 
other drugs ; the pressure of tumors upon the vessels of the 
neck, masturbation, excessive intellectual exertion, and great 
emotional disturbances, such as grief, jealousy, disappointed 
affection, and, above all, excessive mental anxiety. 

In the four cases which we have considered, are we able to 
discover causes which sufficiently account for the production 
of this affection ? In the first there was excessive mental exer- 
tion, which is, as you know, one of the most potent factors in 
causing cerebral congestion, while in the second I am inclined 
to believe that the patient has been addicted to self-abuse, and 
that the nocturnal emissions were the result of an erethism of 
the sexual organs, which had, in its turn, reacted upon the ves- 
sels of the brain and induced their distention. In the third, 
however, we have a number of factors, all combining together 
and acting as causes ; for instance, there is the hereditary pre- 
disposition, which has been directly transmitted, as is demon- 
strated by the patient's eccentric ideas and actions. Then his 
irregular habits, his excessive mental exertion, the extravagant 
use of tobacco and brandy, had already brought his brain into 
such a congested condition that it only needed a great emotional 
disturbance, such as he received at that time from home, to de- 
velop the apoplectic form of the disease. Thus you see that 



206 CLmiCAL LECTUEES. 

there maj be one or many causes either acting slowly or with 
great suddenness. Lastly, we find, in the case of M. C, that 
the constant anxiety which he had undergone, on account of 
the sickness of his wife and the uncertainty of his business 
speculations, had already been suflficient to produce prominent 
cerebral symptoms. Then follow the death of his wife and 
the loss of fortune, and an epileptiform attack is the result, as 
might have been naturally expected, for in his condition one 
of the fully-developed forms of cerebral congestion would be 
easily induced. Thus we have anxiety, which is the most 
powerful of all the emotions, for by it the brain is so excited 
that the mind is kept continually on the stretch, unable to re- 
cuperate its exhausted strength, until finally, worn out, it gives 
rise to actual cerebral disease. 

As the treatment has been described with each case, I will 
briefly detail to you in a few words what course I pursue in 
these cases, so that you may be prepared to treat them proper- 
ly, for you will meet with them in practice more frequently 
than you might anticipate. 

In the active form of the disease your aim is to diminish 
the amount of blood circulating in the cerebral vessels, and, in 
order to accomplish this successfully, you must lessen the force 
of the cerebral circulation, and also the quantity of blood in 
the brain. In the passive form, however, your object is to in- 
crease the intensity of the cerebral circulation, while at the 
same time you diminish the amount of venous blood in the 
vessels of the brain. I never employ the lancet in these cases 
of cerebral congestion, and I doubt very much the propriety 
of so doing, but I frequently apply a couple of leeches inside 
the nostrils or to the temples, or a few cups to the nape of the 
neck. I believe, however, that the beneficial result is more 
speedily effected when the haemorrhage takes place from the 
nose, as the cerebral vessels are by this means directly acted 
upon. 

You are always to look out for and discover the cause, 
and if possible remove it, as that is of the utmost importance, 
before resorting to other means. We happily possess in the 
bromides an agent which acts upon the calibre of the cerebral 
vessels, and diminishes the amount of blood circulating in them. 



CEEEBEAL CONGESTIOiT. 207 

Of all remedies, none in my experience is so beneficial in de- 
pleting tlie overdistended vessels as some one of the bromides, 
and I make use of those in severe cases which contain the 
largest quantity of bromine, for this is the efficacious part of 
the drug. Greatly-increased experience of this agent has con- 
vinced me of the importance of using large doses in order to 
obtain the physiological efiects. I generally employ a satu- 
rated solution of the bromide of potassium, which I administer 
in teaspoonful doses three times a day, well diluted in water, 
so that the patient will get about thirty grains of the bromide 
with each dose. The bromide of sodium may be used in a 
like manner. • The bromides of lithium and calcium are to be 
taken in doses of fifteen or twenty grains three times a day, 
and in many cases are preferable to the bromide of potassium, 
which causes much constitutional disturbance in some instances, 
and they also contain a much larger percentage of bromine. 
The monobromated camphor is another excellent remedy, 
where you desire to produce a stimulant efiect, and at the same 
time contract the cerebral vessels. The dose of this is five 
grains three times a day, or oftener, as circumstances require. 
It should be made up in pills. The oxide of zinc is also an- 
other powerful agent in relieving cerebral congestion, as well 
as a tonic. It can be given in doses of two grains three times 
daily, in conjunction with the bromides. As it is not solu- 
ble in water, care must be t^ken that the bottle be well 
shaken so as to equally distribute the amount. After the 
lapse of ten days or two weeks it will be found that the cere- 
bral vessels have contracted, and that the patient is suffer- 
ing from debility and mental depression, the result of the con- 
gestion. It is now expedient to make use of tonics, in order 
to build up the nervous system, and for this purpose I either 
employ an extemporaneous prescription of strychnia sulph., 
gr. j ; ferri pyrophosphatis, quinise sulph., aa 3 i ; acidi phos- 
phorici diluti, zingiberis syrupi, aa § ij ; M. ft. mist. Dose, a 
teaspoonful thrice daily in water, or some one or more of these 
remedies separately. In other cases I use the phosphide of 
zinc, which I esteem very highly, in doses of a tenth of a grain 
three times a day. Fat in some of its various forms is an ex- 
cellent adjuvant in repairing the debilitated nervous tissue. 



208 CLINICAL LECTUEES. 

Where there is great heat of the head, ice may be applied 
constantly in India-rubber bags, and it will generally afford 
great relief to the patient. The bodily functions are to be care- 
fully observed, and regulated, if in an abnormal condition, by 
appropriate remedies. Thus, constipation is to be relieved by 
an enema of warm water and oil, and, if the urine be scanty, 
saline diuretics are indicated. The patient should be instruct- 
ed to avoid the recumbent position as much as possible, and 
he should sleep in an easy-chair, so as to gain the advantage of 
the erect position, in order to facilitate as much as possible the 
flow of blood from the head. His food should be nutritious 
and digestible, and he should take plenty of exercise in the 
open air. The skin should be kept in a healthy condition by 
means of the Turkish bath, or by frequent bathing and subse- 
quent rubbing with a crash towel. Stimulants are useful in 
the passive variety of the disease, in order to increase the force 
of the cerebral circulation, and here we find alcohol in some 
one of its forms is often very efficacious ; while in other in- 
stances, the internal administration of the carbonate of ammo- 
nia, or the inhalation of sulphuric ether in small quantities 
several times a day, is attended with excellent results. At the 
same time the bromide, in some form, must be given in order 
to fulfill the most important indication, that of contracting the 
dilated venous vessels. 

Lastly, we have a powerful agent in the constant galvanic 
current in lessening the calibre of the cerebral vessels and im- 
proving the nutrition of the brain, and this is not only useful 
in the active but also in the passive form of cerebral conges- 
tion. In regard to the mode of its application, we have already 
dwelt upon that subject at some length on a previous occa- 
sion. 



EPILEPSY. 209 



LECTUEE XVI. 



EPILEPSY 



To-day I have liad brought to the clinic some very interest- 
ing cases of epilepsy, and shall try to demonstrate to you as 
clearly as possible the prominent phenomena which are met 
with in this class of patients. You know that this is one of 
the most common affections of the nervous system that you 
will be called upon to treat in practice, and yoii should there- 
fore be well prepared to recognize it under any of its manifold 
manifestations. 

By epilepsy we mean that condition which is characterized 
by paroxysms of more or less frequency and severity, during 
which consciousness is lost, and which may or may not be 
marked by slight spasm, or partial or general convulsions, or 
mental aberration, or by all of these factors combined. The 
prominent and characteristic feature of an epileptic paroxysm, 
whether it be of the grand mal or t\iQ petit mat variety, is loss 
of consciousness, for, if this do not exist, there is no epilepsy 
properly so called. 

Occasionally, however, in aborted seizures, there may be a 
kind of semi-consciousness present, but the patient, when the 
attack has passed off, has no recollection of its phenomena. 

You know that, in my didactic lectures upon. this subject, 
I told you that many authors recognize only two varieties of 
this affection, the grand mal^ or severe seizure, and ihQjpetit 
mal^ or light seizure. I have, however, been in the habit of 
dividing this disease into four distinct forms, which seems to 
me to be a more proper and precise classification than that 
which has been generally adopted. 

As I intend to illustrate these different divisions by cases, 
as far as practicable, it will not be inappropriate for me, at this 
time, to refreshen your memories by giving you the classifica- 
tion which I make use of: 
^ 1. Momentary unconsciousness without marked spasm. 

2. Unconsciousness with evident though local spasm. 

14 



210 CLINICAL LECTURES. 

3. Unconsciousness with, general tonic and clonic convul- 
sions. 

4. Irreo^nlar or aborted attacks. 

These four divisions may be met with either separately or 
combined, or there may be certain complications, such as pa- 
ralysis or mania, which are not included in this classification. 
You may have the attack come on very suddenly wdthout any 
premonitory symptoms, or it may be ushered in by prodro- 
mata, which, as a general rule, only precede the paroxysm by 
a very short lapse of time, while, in other cases, there are well- 
marked manifestations of an approaching attack for a consid- 
erable period. 

You will also find that, in some patients, the seizures take 
place only during the day, in others they occur at night dur- 
ing sleep, while there are cases in which the paroxysms come 
on both during the day and the night. 

In the majority of epileptics, the premonitory symptoms 
are so immediate as to form a part of the paroxysm ; while, in 
many instances, the first indication we have of an approach- 
ing seizure is the attack itself. 

The precursory phenomena may manifest themselves in 
any part of the body, not only differing in situation, but also 
in character ; and they may vary from a simple attack of ver- 
tigo to sensations of almost any kind which can well be ima- 
gined, and these may be few or many in number. 

In some instances we have a well-defined aura, which is a 
sensation that commences in some distant part of the body 
and is rapidly propagated toward the head, and which, as it 
usually is of the same character in subsequent attacks as it 
was in the first, is a valuable indication of an approaching 
seizure. As soon, however, as the aura has apparently reached 
the head, the x^atient becomes unconscious. 

With these few preparatory remarks, I will now proceed to 
read you the following history : 

Case I. Ejpilejpsy, Petit Mai and Grand Mai. — " J. F. 
is thirteen years of age, was born in ISTew York City, and, until 
two years ago, was a hale, hearty little fellow, always having 
had the best of health. The first thino- that attracted the at- 



EPILEPSY. 211 

tention of his mother was, a change in his disposition and con- 
duct, which at times was more marked than at others. Instead 
of being cheerful and fond of play, he would become sulky 
and depressed in spirits, and, when asked what was the matter, 
he wonld reply 'that he did not feel well, and that his head 
troubled him.* 

" One day, however, his mother noticed that he did not re- 
ply when she spoke to him, and, on looking to ascertain the 
canse, she discovered that he w^as nneonscious, that his eyes 
had a peculiar appearance, and that his face was distorted, 
being drawn to one side. In the course of time these at- 
tacks began to occur more frequently, and took place not 
only during the day but also the night, and w^ere accompanied 
by the dribbling of saliva from his mouth. When an attack 
came on at night it always awoke him, and with a start he 
would sit up and catch tightly hold of the side of his bed for 
a few seconds until it was over. During the paroxysm he was 
perfectly unconscious, and the only manifestations that were 
observed were the spasms of the muscles of the face on one side, 
the fixedness of the eyeballs, and the clutching of the side of 
his bed, together with dribbling of the saliva. 

" At first he Iiad two or more seizures in the course of 
twenty-four hours, but these gradually increased in frequency, 
until the lapse of a year, when there were superadded attacks 
of the grand mal, which were characterized by the following 
phenomena : 

" He first felt a peculiar tingling sensation, which com- 
menced in the apex of the tongue, and then quickly mounted 
to the head, when he became unconscious. Before, however, 
losing consciousness, he became very pale and felt dizzy. TSen 
followed loss of consciousness and tonic rigidity of the muscles 
of one side of the body. This lasted for about ten seconds, 
and then followed the second stage, marked by clonic convul- 
sions, redness and lividity of the face, frothing at the mouth, 
and irregularity of the respiration, which generally continued 
for about a minute, and then he passed into the condition of 
stupor, which lasted for an hour or more, but, if the attack oc- 
curred at night, he would not awake until morning. 

" As the lesser attacks increased in frequency, they w^ere 



212 CLmiCAL LECTUEES. 

accompanied hj spasms in tlie muscles of tlie tliroat, which 
gave rise to a peculiar gurgling sound. For several days the 
attacks of ^etit mal would be repeated at frequent intervals, 
and then would follow a grand-mal seizure, when for a few 
days he would be free from paroxysms of either kind. When 
the lesser attacks occurred in the daytime, he always caught 
hold of some article of furniture, and remained standing until 
it had passed ; but, when the paroxysms of grand mal came 
on, he not only lost consciousness completely, but fell to the 
floor suddenly. A year before coming under our observation, 
his mother was able to calculate very exactly when a seizure 
would take place, from his ill-temper, extreme nervousness, 
and discontent, which were the precursors of an approaching 
paroxysm. He has had two very severe attacks of tlie grand 
mal, and after one of these his arms were powerless for some 
time. 

" On another occasion he had a continued series of convul- 
sions, lasting for about two hours, which was the cause of his 
mother again seeking medical advice. Within the last six 
months she has found that he frequently wets his bed at 
night. There is no hereditary taint in the family, so far as 
relates to diseases of the nervous system. 

" On admission to the Out-door Department of the ]N'ew- 
York State Hospital for Diseases of the Nervous System, J. 
F. was in the following condition : 

" He was very pale and anaemic, and had the characteristic 
appearance of a person suflering from epilepsy. His pupils 
were dilated ; his facial expression was stupid in the extreme. 
His memory was impaired ; his ideas were very much con- 
fused, and his morale greatly perverted. He was unable to 
do even small en-ands for his mother with any degree of cer- 
tainty, for he would either lose the money she had given him 
or forget the errand upon which he had been sent, so that he 
could not execute it. He complained of a dull feeling of con- 
striction in his head, and was morose and irritable in the ex- 
treme. There were on his forehead and chest little spots of 
extravasated blood, which did not disappear upon pressure, 
and which betokened a recent attack of the convulsive seizure, 
which he said he had had upon the preceding day. 



EPILEPSY. 213 

" Frequentlv there ^vere convulsive movements of the face, 
attended by loss of consciousness, together with glottis spasms, 
dribbling of saliva, and a loud, gurgling noise in the throat. 
He at times passes his urine involuntarily during sleep, and in 
the morning he complains of headache and nausea after a 
nocturnal attack. Increased irritability, perversion of char- 
acter, and mental obtuseness, are the precursors of an impend- 
ing attack of the grand mal. 

" His appetite is poor, his bowels regular, and his sleep is 
frequently troubled by disagreeable dreams. His heart and 
lungs are healthy. 

" The retinal circulation is normal. The attacks of ^etit 
mal occur at present very many times a day, while those of 
the grand mal come on at regular intervals, varying from a 
few days to two weeks. There seems to be no cause, either 
predisposing or exciting, which can be ascertained, that is of 
sufficient importance to accoimt for these epileptic phenomena. 

" He was immediately placed upon a saturated solution of 
the bromide of potassium, of which he took a teaspoonful 
three times a day, well diluted in water, but without any per- 
ceptible effect. The amount of the bromide was gradually 
increased, until he took one hundred and fifty grains as a 
daily allowance, which, in the course of a week, produced the 
well-marked effects of bromism, and the amount was then 
diminished to one hundred and twenty grains a day, as he 
had had no fits since being brought fully under its influence. 
For over three months he was entirely free from an attack, 
but at this time he omitted to take his bromide, and the fits 
returned. As he was very much run down in health, he was 
ordered to take only ninety grains of the medicine, but his 
attacks still continued. The amount was again increased to 
one hundred and twenty grains a day, which has been effica- 
cious in completely stopping them for the last eight months, 
during which period he has not had a single attack. Owing 
to his impaired appetite, the broken-down condition of his 
general health, and the trouble which he experienced from 
the abscesses which had formed in different parts of his body, 
the medicine was at times reduced to ninety grains a day, 
but almost immediately there were indications of an approach- 



214 CLIXICAL LECTUEES. 

ing attack, so that it was not considered safe to give him less 
than one hundred and twenty grains, which amount seemed 
to keep the fits completely under control, which no smaller 
quantity was able to do." 

In this patient you notice that there are two different 
kinds of attacks, which are sufficiently distinct to enable us 
to distinguish the one from the other. There are paroxysms 
of the jMit mal^ or lighter seizure, which are characterized by 
sudden loss of consciousness, lasting for a very short period, 
during which the patient remains in a fixed position, catching 
hold of some object, which he firmly grasps, dm'ing its con- 
tinuance, with his hands ; and there are also convulsive move- 
ments of the face, which are well marked, and limited to one 
side of that organ, more particularly around the corners of 
the mouth, which are accompanied by the dribbling of saliva, 
which is due to the temporary paralysis of the buccal muscles. 
As the disease has progressed, we find that the muscles of the 
pharynx have become involved, giving rise to glottis spasms ; 
and that, when the attacks take place at night, the contents of 
the bladder are evacuated. 

From these phenomena we are able to diagnosticate that 
variety which I have classified as unconsciousrpess, with evi- 
dent though local spasms, and which is characterized by loss 
of consciousness, attended by convulsions, which are at times 
very slight in degree, and at other times well marked. Yet 
they are always limited in extent. As for example in this 
patient, there were spasms of the muscles of the hands and of 
the anodes of the mouth on one side, too;ether witli convul- 
sions of the muscles of the pharynx, which are by no means 
uncommon occurrences. 

In other instances the tongue is pushed forward between 
the teeth, in which position it is injured by the spasmodic 
contraction of the muscles of the jaw, or there is a sudden 
rotation of the head, or a momentary strabismus, or a tugging 
at the hand, or the grasping of some object, as a chair, which 
you will remember was the case with this patient. All these 
acts are performed in a state of unconsciousness. Although 
they may at times appear to have been accomplished in ac- 



EPILEPSY. 215 

cordance with the will, nevertheless they are perfectly auto- 
matic ; and, after the attack has passed, th^s patient has no 
recollection of any thing that has transpired. These attacks 
were ushered in by prodromata, which were manifested by 
changes in the conduct and the disposition, and which, in the 
present instances, preceded the attack by a considerable inter- 
val. Then it will be observed that the paroxysms seldom last 
over a minute, while their average duration is generally much 
shorter. In many cases there are no subsequent phenomena 
after an attack of this kind ; the patient immediately recovers 
his consciousness, and feels quite himself again. But this is 
by no means always the case ; for, after a very mild seizure, 
some patients suffer from headache, vertigo, and confusion of 
ideas, to the same degree as if they had had a grand-mal 
seizure. The lighter attacks increase in frequency as the dis- 
ease progresses ; and, as a general rule, they occur at much 
shorter intervals than the fully-developed paroxysms. It is by 
no means uncommon to find different varieties of epilepsy in 
the same individual, as we have in the case before us. 

Besides the frequent attacks of the jpetit Trial, there have 
been occasional paroxysms of the grand mal^ which began 
to make their appearance after the lapse of a year from the 
inception of the epileptic seizure. These have also increased 
in frequency, so that at the present time they recur about once 
a week. They are preceded by well-marked prodromata, 
which are increased irritability, perversion of character, and 
mental obtuseness, together with an aura which commences in 
the apex of the tongue, and then rapidly ascends to the head, 
when the patient loses consciousness and falls to the ground 
as if struck with a club. 

There is no cry, but merely extreme pallor of the coun- 
tenance and severe vertigo, which immediately precede the 
loss of consciousness. 

Then follows the stage of tonic rigidity, which is usually 
of short duration, seldom lasting more than a few seconds, and 
during which the respiration is greatly impeded, the pupils 
dilated, the countenance livid, the body drawn to one side, the 
pulse weak and rapid ; there are strabismus, throbbing of the 
carotids, tonic rigidity of the muscles of the neck, and those 
of one side of the body, and entire abolition of sensibility. 



216 CLINICAL LECTURES. 

Then this stage passes away, and convulsions of a clonic 
character supervene. These are present on only one side of 
the body, and keep the limbs in constant agitation. The livid- 
ity of the face still continues ; the respiration is irregular ; 
there is frothing at the mouth, but you will observe the 
tongue is not bitten, which shows that the roots of the hypo- 
glossal nerve are not involved. The muscles of the neck do 
not become relaxed during this stage, as is seen from the con- 
tinuance of the livid hoe of the face, which is now at its acme. 
After the lapse of a minute or more, this stage passes away, 
and the patient either begins to retui'n to consciousness or 
passes into»a condition of stupor which continues from a 
few minutes to an hour or more. This case illustrates very 
well the main features of these two forms of epilepsy ; but, as 
I intend to show you a case of the grand mal^ which is not 
complicated with any other form of the disease, I will merely 
call your attention to a few points before passing to the con- 
sideration of the treatment. 

You know that the motor power of epileptics is as a gen- 
eral rule weakened, without there being any well-marked 
paralysis, and, even in such exceptional cases as the one 
before us, we see that, even where there is decided paraly- 
sis, it does not last for any considerable period, but quickly 
disappears, like that of cerebral embolism. Considerable in- 
tellectual impairment is the exception rather than the rule 
in epileptics. Iteynolds has found that the mind was per- 
fectly normal in thirty-eight per cent, of his cases, and, from 
my own experience, I have seen many cases in which the 
disease, even when fully pronounced, was unattended by 
mental chano^e. But, nevertheless, the mind sooner or later 
becomes involved, and a first attack late in life is often the 
precursor of subsequent dementia. But this fact is to be 
particularly borne in mind, that the mild attacks, unattended 
by convulsions, are much more apt to produce impairment of 
the intellect than the more severe seizures. Even in the inter- 
vals between the paroxysms these patients may exhibit not 
only disorders of the intellect, but likewise their sensorial and 
motor functions may be involved. You remember the degree 
of impairment of the mind of this patient when he first came 



EPILEPSY. 217 

to tlie hospital. His memory was impaired to an extreme de- 
gree, his ideas were confused, and his whole intellectual life 
seemed to be in abeyance. Such was his condition before he 
ever had an attack of grand mal — and such has been the 
experience of all those who have seen many epileptics, that the 
attacks of i}iQ petit mal are more likely to produce this mental 
change than those of the grand mal. 

Some of you may remember this boy when he was present at 
this clinic a year ago. He was then placed upon the bromide 
of potassium, in large doses, and these doses have been contin- 
ued, and at times increased, so that now he has not had a fit for 
eight months. He is at present taking one hundred and twenty 
grains per day. He has taken as high as one hundred and fifty 
grains per day. But one hundred and twenty grains is his or- 
dinary daily allowance. As you see, he is broken down in ap- 
pearance, has large abscesses in his neck, and is altogether in a 
bad condition. But this is better than to have epilepsy. This 
attenuated form, these pustules upon the face, and boils or 
abscesses upon the neck, are all the effect of the large doses 
of the bromide of potassium which he has taken. But, I 
think he should continue the medicine for three or four months 
longer at least. All these effects will disappear very rapidly 
as soon as the medicine is stopped ; but you can help them dis- 
appear by the assistance of strong, nutritious food. It would 
be the height of folly now to stop the medicine on account 
of the effects it has produced upon his system, for by so doing 
the fits would undoubtedly immediately return. As you see, 
his memory is now quite good in comparison to what it was. 
His ideas are not at all confused, and he reasons and compre- 
hends very well indeed for a boy of his age. He has now no 
pain in the head ; but, as soon as the medicine is cut down to 
ninety grains a day, all his premonitory symptoms come back 
immediately. I believe it is better to continue the medicine 
all his life than for him to have epileptic paroxysms. 

An important fact to notice in this connection is, that all 
the disagreeable effects of the medicine will wear off in about 
six months, so that in the course of time it will cease to pro- 
duce boils, abscesses, and the other disagreeable effects of the 
bromic cachexia, which, I believe, is favorable to the eradica- 



218 CLINICAL LECTUEES. 

tion of epilepsy, and that is the reason why I endeavor to pro- 
duce bromism, as it appears to so alter the whole organism of 
the patient that, wdien it ceases to exist, there is no danger of 
the disease returning. Perhaps the occurrence of these large 
abscesses at the back of the neck is beneficial to him. I have 
seen cases where the addition of a seton to internal remedies 
has effected a favorable result. A gentleman from Wheeling, 
West Virginia, came under my care about eighteen months 
ago for epilepsy, and, with large doses of the bromide of potas- 
sium, I could obtain no favorable result. In addition to the 
bromide, I now passed a seton deeply through the muscles of 
his neck, and the fits at once stopped. These two things were 
necessary to be employed in his case, in order to arrest the 
progress of the disease. He has not had an attack for fifteen 
months, and he has continued to wear the seton all this time. 
Ordinarily, when a patient has passed fifteen months without 
a fit, they do not return, but occasionally they will come back 
in some unexplained way. I have begun to reduce this gen- 
tleman's medicine somewhat by diminishing his daily allow- 
ance about thirty grains. I shall continue the remainder for 
about two months, and then cut off thirty grains more, and so 
on until the medicine is stopped, a process which will take 
about six months. 

[I^OTE. — J. F. continued under our care until July, 1873, 
a period of about eighteen months, and during fourteen months 
of this time he had no attacks of either the grand mal or the 
petit mal. At the end of twelve months he had so much im- 
proved in general health, the boils and pustules on his face 
having entirely disappeared, that the amount of his medicine 
was diminished to ninety grains a day, which quantity he con- 
tinued to take for a period of two months, while his general 
health, his mind, his memory, his conduct, his temper, all 
seemed to gradually improve. As fourteen months had now 
passed without his having a single fit, we told him to still con- 
tinue taking the ninety grains daily for a few months longer, 
so as to be sure of eradicating the disease. He then passed 
from under our observation, but, some time after, his mother 
informed us that he had had a continued series of fits, wdiich 



EPILEPSY. 219 

lasted several lionrs, and wliich are commonly called the 
status epilepticus. He had, however, as far as we were able 
to learn, taken his medicine regularly np to the time when 
this attack occm'red. Since then the patient has passed from 
under our care. — T. M. B. C] 

Having shown you a patient who was afflicted with two 
varieties of epilepsy, I will now present you another who is 
suffering from the grand mal only, and whose history is as 
follows : 

Case IT. Epilepsy. Grand-Mai Seizures. Nocturnal 
Form. — '' C. R. is thirty years of age, was born in Ireland, is 
single, and a cooper by trade. He is a strong, muscular man, 
and had been quite free from sickness until 1861, when he had 
his first epileptic attack. There is no predisposition to epi- 
lepsy, or any other disease of the nervous system, in his family, 
either as regards the direct line or its collateral branches, so far 
as could be ascertained. He has been in the habit of drinking 
spirits, but never to excess. Some years prior to the com- 
mencement of the fits, he had been addicted to onanism, which 
he practised very frequently, and which he continued up to 
the time of their first occurrence. Diu-ing this period he often 
suffered from nocturnal emissions, which were accompanied 
with voluptuous dreams. 

" During the year 1861 he went to bed one night feeling 
quite well, although somewhat fatigued, and soon fell asleep. 
How long he had continued in this condition he was not 
aware, but suddenly he was aroused by a feeling of impending 
danger, as if something dreadful was about to happen. He 
then called out loudly for assistance, to his mother, who was in 
an adjoining room, and who came immediately to him. When 
she arrived, he was unconscious, his face was livid, his mouth 
was covered with foam, which was tinged with blood, and the 
left side of his body was every now and then thrown into vio- 
lent involuntary convulsions, while the right seemed to be un- 
affected. After the lapse of two or three minutes the patient 
became more or less conscious, the convulsive movements of 
the limbs ceased, and he now complained of feeling heavy and 



220 CLI]^ICAL LECTURES. 

stupid, but almost immediately lie passed into a state of stupor 
from which he did not rally until morning. Then he felt very 
badly. He had a dull, aching pain in his head, accompanied 
by nausea. He was dizzy at times, and he loathed the very 
sight of food. In the com^se of a day or so these symptoms 
passed away, and he felt quite himself again. At first these 
attacks occurred once in every two months, and were very 
severe in character ; but after a while they increased in fre- 
quency, so that lie would have a fit regularly once a week for 
a period of two or three months, and then a remission would 
take place for a month or more, during which time he would 
have only one attack. These fits usually came on after he 
had been asleep about half an hour, and consequently were of 
the nocturnal variety. He was admitted to the Out-door 
Department of the 'New York State Hospital for Diseases of 
the Nervous System, September 19, 1871. 

" At that time his condition was as follows : His memory 
is somewhat affected, especially as regards dates and familiar 
names. His intellect is far from active, although on some 
points he is quite clear ; but he does not seem to be able to fix 
his attention upon one subject for any considerable length of 
time. His aspect is characteristic of the disease from which he 
suffers. He complains of unpleasant sensations in the epigas- 
trium and in other parts of the body. He is always awakened, 
before losing consciousness, by a severe spasm,which commences 
in his left hand and rapidly travels up his arm toward his head, 
so that he has time enough to call out for help before he be- 
comes unconscious. When, however, his left arm is violently 
seized at the time that he first feels the aura commencing in the 
left hand, the attack does not take place, but is cut short by 
this means. When his fits do not take place shortly after going 
to sleep, they occur later, but always at night. He does not, 
therefore, complain of dizziness or headache before the attack, 
but instead of these phenomena there are twitchings of the 
muscles in the left lower extremity, together with the aura, 
which has already been mentioned. His tongue presents the 
signs of several injuries which it has received during these noc- 
turnal attacks, by being caught between the teeth and badly 
bitten during the clonic convulsions of the muscles of the jaw. 



EPILEPSY. 221 

He has never suffered from incontinence of urine or of faeces. 
Kor are there any injuries about his head or face, which would 
show that he had experienced an attack during the day. He 
is depressed and melanchohc, and little inclined to attend to 
his business. 

*' When he came to the hospital, he had had only one at- 
tack in the last two months. Latterly, however, he has been 
warned of the approach of a seizure by a clonic spasm in 
the sterno-cleido-mastoid muscle of the right side, which 
slowly and gradually draws his head toward the right shoul- 
der for a certain distance, and then relaxes. This occurs 
consecutively four or five times during the day, and then 
the aura commences at night, and the fit follows as soon 
as it has reached the head, which ordinarily is in a very short 
space of time. These violent twitchings of the muscles of the 
neck are not accompanied with loss of consciousness. The 
fits have, as has already been mentioned, increased in fre- 
quency ; but, as they have increased in this respect, they have 
become less severe in character. Ophthalmoscopic examina- 
tion of the retinal circulation shows that the structure at the 
base of the eye and its vessels are in a perfectly normal condi- 
tion. There are no petechise upon the face or chest. The 
IDatient, during the ten years that he has had this disease, has 
not had any medical advice. His pupils are much dilated at 
present, and his bowels are constipated. 

" He was immediately put upon a saturated solution of 
the bromide of potassium, of which he took a teaspoonful, well 
diluted in water, three times a day. At the end of a week he 
had another attack, which was not as severe as usual. As he 
complained of much distress in the epigastrium and abdominal 
region, we discontinued the bromide of potassium, and substi- 
tuted the bromide of sodium, which he took in thirty-grain 
doses three times a day. Whenever he felt the aura coming 
on, his mother was instructed to grasp his arm firmly, so as to 
prevent the fit ; but, as he has had no attack in ten months, 
she has not had occasion to resort to this procedure." 

This case, although not as explicit in many of its symp- 
toms, is, nevertheless, much more full in its details than the 



222 CLcacAL lectuees. 

cases you Avill ordinarily meet witli of the nocturnal form. It 
is often the case that fits take place during sleep, and the pa- 
tient is unaware of their occurrence. In the morning he 
awakes feeling stupid, and as though he had not enjoyed his 
regular night's repose ; he may have headache, vertigo, and 
nausea. His limbs may be sore from the severe convulsions 
they have experienced during his unconsciousness, and, when 
he arises, he is unable to account for the pain and soreness 
from which he suffers, or he may have bitten his tongue, and 
this may have escaped his notice, except he be questioned in 
regard to that fact, when he will remember that the pillow 
was stained with bloody saliva, and that for one or two days 
he had an unpleasant sensation of pain in his mouth when 
he masticated his food. He may have passed his water or his 
feeces involuntarily, and the reason for so doing he may have 
attributed to some slight indisposition, or he may have injured 
himself during sleep ; and yet, even then, he is ignorant of the 
the true cause of his wound. 

I have met with many of these symptoms in the large num- 
ber of epileptics which have fallen under my observation, so 
that, whenever I find a patient suffering from one or more of 
these phenomena, I inquire carefully into his history, and I 
generally succeed in discovering that the cause of these abnor- 
mal symptoms is due to nocturnal epilepsy. Some time ago I 
was called to see a patient, in consultation, who was supposed 
to have had an attack of cerebral haemorrhage during sleep. 
On carefully examining the patient, who was a very muscular 
young man, I discovered that the head of the humerus was in 
the axilla, and that there was a dislocation which accounted 
for the loss of motor power in his right arm. He told me 
that he had retired that night feeling remarkably well, but 
that, on arising the following morning, he found his shoulder 
very painful, and that he was unable to move his arm. He 
also complained of soreness of the muscles on the right side of 
his body, which he could hardly touch without causing 
pain. On protruding his tongue, I observed that it was bit- 
ten, and there were the marks of former cicatrices, which con- 
vinced me of his having had a number of epileptic attacks. 
He complained of headache, and I noticed some petechise upon 



EPILEPSY. 223 

his tliroat and cliest. From these phenomena, I knew very 
well that this young gentleman had had a fit during the night, 
and, during the violent convulsive stage, his arm had been dis- 
located. 

In another case which came under my care, the patient, 
a young lady, came to consult me in regard to her head. 
She mentioned, incidentally, that she was in the habit of 
passing her water involuntarily, once in about every two 
weeks, while she was asleep. On questioning her closely, I 
found her memory weak, her ideas confused, and that she 
suffered the next morning, after these involuntary losses of 
urine, with a severe headache. From the impairment of this 
young lady's mind, which was very well marked, the period- 
ical occurrence of her loss of urine — which was almost invari- 
ably followed the next morning by a severe headache and an 
increased confusion of ideas, and which was present at no 
other time — impressed me strongly with the belief that she 
was subject to epilepsy. Nor was I mistaken, for a short time 
after she had a well-pronounced attack of the grand mal. 

From these iostances you will perceive that there is no 
invariable law in regard to the occurrence of any particular 
form of epilepsy, or of symptoms. As a general rule, how- 
ever, the nocturnal attacks are not accompanied by such well- 
marked premonitory symptoms as those of the diurnal, for the 
reason that the patient, being in a condition of sleep, does not 
take cognizance of existing impressions, or else these phenom- 
ena do not exist. Generally, the attack takes place suddenly, 
and the patient is either awakened from his sleep, and utters 
an inarticulate cry of a peculiar kind, and which has been 
compared to the bleating of a young lamb, or else he passes 
into a state of convulsion, without ever having been aroused. 
"Without going minutely into details of the symptomatology 
of a grand-mal seizure, which I have already described at some 
length in the preceding case, I will rather call your attention 
to some of the phenomena which we have not as yet care- 
fully considered, and which differ in some respects from those 
which we have already observed. 

The disorders of motility are very well manifested in the 
present instance. There are clonic convulsions of the sterno- 



224 CLIinOAL LECTUEES. 

cleido-mastoid muscles on the right side, ■^liicli are pres- 
ent during the day, and which forewarn the patient, almost 
to a certainty, that he will have a fit the following night. 
Before this supervenes, however, he experiences twitchings in 
the left leg and a severe pain in the left hand, which is caused 
by a violent tonic spasm of the muscles of that member. 
These derangements of the motor power are present in many 
cases, and betoken an increased excitability of the reflex 
power of the spinal cord. We also find that there are impair- 
ments of sensibility, which are characterized by vertigo, 
headache, pain and numbness in different parts of the body, 
and from which this patient has not been free. You recollect 
that, during the convulsive seizure, his tongue was severely 
bitten by being caught between the teeth during the contrac- 
tion of the muscles of the jaw, and in this way we can account 
for the froth, tinged with blood, which escaped during the fit, 
from his mouth. In those instances where the tongue is in- 
jured, we have strong reason to believe that the roots of the 
hypoglossal nerve are in a state of hypersemia, for it is only in 
the convulsive form of the disease that this accident happens. 
I have already spoken to you of an aura which, in the pre- 
ceding case, commenced in the apex of the tongue, and then 
so quickly mounted to the head that the patient almost im- 
mediately became unconscious. In the patient before us, how- 
ever, it was ushered in by a feeling of pain in the left hand, 
which was so severe in character as to awaken him from his 
sleep. J^evertheless, before it ascended his arm and reached 
his head, he had plenty of time to cry out and inform those 
around him that the attack was about to take place. It 
would have been easy to have stopped the fit at this time if 
his left arm had been immediately tightly compressed, either 
by a strap or by the hand of any person who was near by at 
the time. I have known an attack to be cut short by a person 
suddenly changing his position ; another can arrest the fit by 
putting salt in his mouth ; and in other instances, where the 
aura commences in some distant part of the body, a ligature, 
tied tightly around the limb, above the starting-point of the 
aura, will be sufficient to prevent a seizure. 

In all cases where there are sensations of numbness, of 



EPILEPSY. 225 

tino'ling, of cramp, or of pain experienced by individuals in 
different parts of the body, and wbicb proceed rapidly toward 
the bead, and wbicli are in reality auras, properly so called, it 
is always expedient to strive to arrest tlie fit by means of the 
ligatm-e, especially if the aura commences in some one of the 
extremities, as a hand or foot. 

Like the attacks of the petit mal^ the grand-mal seizures 
increase in frequency as the disease progresses ; but, usually, 
the latter become milder as they are more frequent. I have 
been in the habit for several years of examining, with the 
ophthalmoscope, the fundus of the eye of all epileptics who 
have come under my observation, and in a large number of 
these, in which there existed either cerebral congestion or 
cerebral ansemia, I have obtained valuable information, which 
has aided me very materially in effecting a cure. ISTeverthe- 
less, there are some cases in which there can be discovered no 
changes in the cerebral circulation ; and to this category be- 
long the two cases which we have considered to-day. This 
patient has now been under treatment one year, and, during 
this time, he has taken thirty grains of the bromide of sodium, 
well diluted with water, three times a day. After passing ten 
months without having a fit, he inadvertently omitted taking 
his medicine, and the fits returned. But, since then, I have 
increased the amount of the bromide to a hundred grains 
daily ; and even now, as you see, he exhibits no symptoms of 
bromism, and he has had no fit for over six weeks. When I 
touch the base of his tongue or fauces with the handle of this 
pencil, you perceive that he is nauseated, and the muscles of 
his throat are at once susceptible to the touch, which shows 
that he is not yet taking a suflicient amount of the medicine; 
for, as soon as he is under its influence, the reflex faculty of 
the pharynx will be lessened. In cases which have lasted as 
long as this, we can rarely hope for a favorable termination ; 
but, considering the happy effect which the bromide has ex- 
ercised upon this patient during an interval of ten months, 
we can well anticipate a cure in this case, if the patient will 
only persevere in taking the remedy regularly for a period of 
eighteen months or more. It is not always easy to explain 
how the bromide acts in so favorable a manner in some of 

15 



226 CLINICAL LECTURES. 

these nocturnal cases of epilepsy, but such, nevertheless, is the 
fact, that in some few instances of this form of the disease it 
is efficacious in arresting the paroxysms. Generally, however, 
in the nocturnal form of epilepsy, strychnia will be found to 
be more beneficial than the bromide, and in the non-convul- 
sive seizures rather than the convulsive. 

[Note. — C. H. continued under our observation two months 
after the amount of his bromide was increased to a hundred 
grains daily, and during that time he had no return of the 
iits. We then lost sight of him, and he has not since returned 
under our care. — T. M. B. C] 

Case III. Gastrio ^pilepsj/. Grand Mai. Nocturnal 
Form. — "A. C, aged twenty-eight ; was born in the United 
States; is single, and a house-keeper by occupation. Had been 
the subject of epilepsy for four years when she first came under 
our care. She was a woman of industrious and steady habits, 
and had never been sick until the commencement of these epi- 
leptic seizures. Her grandmother on her father's side had been 
afflicted with epilepsy for many years, so that we obtain a 
direct hereditary predisposition to that disease in her case. 
In the winter of 1866 she had her first attack, which occurred 
at night, and was not very severe in character. At this time 
slie was observed, by a friend who was sleeping with her, 
and who was awakened by her convulsions, which lasted a 
minute or so, to be perfectly unconscious ; her eyes were 
fixed ; froth, tinged with blood, issued from her mouth ; her 
hands were clinched, the fingers being drawn strongly into 
the palms of the hands ; her face was livid, and the convul- 
sions appeared to be equal on both sides of the body. In a 
short time these disorderly movements ceased, and she passed 
into a condition of stupor, without regaining consciousness, 
from which she did not arouse until morning. Then followed 
violent headache and nausea, and she complained of soreness 
of her tongue, especially in the act of eating, or in taking hot 
or cold drinks. It was also discovered that she had passed 
her water involuntarily during the night. She was ques- 
tioned closely the next morning in regard to the remembrance 



EPILEPSY. 227 

of the events of the preceding night, but she was unaware of 
what had taken place. 

'' These paroxysms at first occurred about once in three 
months, but have continued to increase within the last four 
years, not only in frequency but also in severity, so that 
when the patient first came under our observation she was 
having a fit about once a fortnight. The only cause that we 
were able to discover, besides the hereditary predisposition, 
was, that, on the day preceding her first attack, she had 
eaten very heartily, before retiring, of corned-beef and cab- 
bage, and this was undoubtedly the exciting cause of the 
epileptic seizure. You will observe that there were no pre- 
monitory symptoms whatever, such as headache, vertigo, an 
aura, glottic spasms, or crying out for help, for she did not 
awaken, but, from a condition of unconsciousness, she passed 
directly into epileptic convulsions. Her seizures have always 
been of that variety which we call the grand mal. They have 
always occurred at night, and have never been over two min- 
utes in duration, both sides of the body being about equally 
convulsed. 

" When the patient first came under our care, her condition 
was as follows : Her skull was well formed and symmet- 
rical ; her memory was good, and her mind appeared to be 
active, although at times she complained of a slight confusion 
of her ideas. There was no defect in her speech, and her 
special senses were unimpaired. There was no weakness 
of her motor power, and the circulation seemed to be active. 
Her heart and lungs were healthy ; her pulse was 76, and, 
although not exceedingly strong, it was regular, and far from 
feeble. Her bowels were constipated, and her digestive func- 
tions somewhat irregular. She complained of a feeling of 
heat and weight in the epigastrium, accompanied with eructa- 
tions and distsntion. Her menstruation was natural and her 
urine healthy. Examination of her eyes, by means of the 
ophthalmoscope, revealed a congested condition of the retinal 
vessels. On examining the tongue, there were numerous 
scars, which showed that this member must have suffered fre- 
quently during these nocturnal attacks. She said that she 
almost invariably passed her water during the seizure. There 



228 CLimCAL LECTURES. 

were no injuries of the head, such as are so often met with 
in those who suffer from the diurnal form of the grand-^nal 
seizures, that could be discerned. After each of these attacks 
she suffers severely, for at least twenty-four hours, with violent 
headache and nausea ; and, as the attacks became severer in 
character, there were well-marked petechias to be found upon 
the forearm and wrists, but they were not observed either 
upon the face, neck, or chest. She had lost much flesh, for 
she was very thin and pale. Her appetite was capricious, and 
her tongue was thickly furred. She had had an attack two 
days before we saw her, and at that time the petechias on her 
forearms and wrists were very noticeable. 

" She was ordered to take six grains of the extract of aloes 
and three grains of ox-gall at night before retiring. The next 
day, as her constipation had been relieved, we prescribed thirty 
grains of the bromide of potassium, three times a day, well di- 
luted in water, together with the thirty-second of a grain of 
strychnia. At the same time the primary galvanic current was 
applied to her brain and sympathetic nerve, three times a week, 
for about ten minutes : at each sitting one pole being placed on 
the forehead and the other on the nape of the neck for a third 
of the time ; for another third, one pole placed on each mas- 
toid process ; and, for the remaining third, one pole rested 
upon the sympathetic nerve in the neck, and the other on the 
first dorsal vertebra. The current was derived from ten cells 
of Stohrer's battery. The patient was put upon a highly- 
nutritious diet, and was instructed to avoid all food that 
would cause gastric irritation. A little over a month after 
the commencement of the treatment she left off taking her 
medicine for a day or so, and the result of this indiscretion 
was a violent fit. After this she continued to take her medi- 
cine regularly for two j^ears, without having had any epileptic 
seizure. At the end of this time she had increased in weight, 
and had greatly improved in general appearance. She had 
now no headache, no nausea, and no involuntary discharge 
of urine. Six months ago we saw her, and there had been no 
return of the fits, although she had ceased taking her medi- 
cine for several months. The application of the galvanism to 
her brain and sympathetic nerve was continued regularly for 
about eight months." 



EPILEPSY. 229 

This case illustrates very well the prominent features of a 
graiid-mal attack of the nocturnal form ; but, without dwell- 
ing longer upon this branch of the subject, I will pass to the 
consideration of another variety of this disease, to which I 
now wish to call your attention. 

Case IY. Ejnlejpsy. Momentary Unconsciousness^ with- 
out evident Spasms. — " Miss J. F., aged seventeen, a young 
lady of refinement and culture, had been subject to sudden 
attacks of unconsciousness for a period of tw^o or three years. 
At first, however, they were so slight in degree that her par- 
ents paid little attention to these absences, as they called 
them, and thought they were of no particular consequence, as 
they did not seem to affect her general health. In time, how- 
ever, they found that her mind and memory were becoming 
considerably involved, and they then sought medical advice. 

"It seems that this young lady had enjoyed excellent 
health until she was about fourteen years old, when she had a 
severe attack of scarlet fever, which had impaired her hearing, 
to a considerable degree, in her left ear. Shortly after her con- 
valescence she began to have these fits of absence, as they 
were called, which her mother very accurately described. 
When engaged in conversation, for instance, she would sud- 
denly stop in the middle of a sentence, her face would be 
deadly pale, her eyeballs would become fixed, and, when her 
mother spoke to her, she did not repl}", but in a few seconds 
she would resume her conversation, as if nothing had hap- 
pened. She had no recollection of her mother speaking to 
her. At other times she will drop whatever she may be car- 
rying in her hand ; and, when she regains consciousness, 
which is always in a very few seconds, she is surprised at 
what has happened, and exclaims, ^How strange I did not 
hear it fall ! how stupid I must have been ! ' She has an 
aunt who is epileptic, and a brother who is insane, and is 
now confined in an asylum. These paroxysms have increased 
in frequency, so that she has a number every day ; but her 
mother thinks they are now no more severe than they were 
three years ago. 

" In the spring of 1870 she came under our care, and at 
that time her condition was as follows : 



230 CLIITICAL LECTUEES. 

" Her head is symmetrical and well formed. Her memory 
is very weak, and her ideas even on simple subjects are greatly 
confused, so much so that she appears to be in a state of im- 
becility. Her emotional system is very easily aroused, by 
even trifling matters. She has at the present time as many 
as six or eight of these seizures daily. They occur at no regu- 
lar intervals, but come on at different times during the day. 
There is simply a loss of consciousness for a few seconds, ex- 
treme pallor of the face, fixedness of the eyeballs, and at times 
she drops whatever she may have in her hand ; but there is no 
evidence of any convulsions in any part of her body, not even 
in the muscles of the eyeballs. Her pupils are dilated, and 
the vessels of the retina, as seen by the ophthalmoscope, are 
small and straight, and the choroid very pale. - Her heart and 
lungs are healthy. Her urine is very copious, and she is in- 
clined to be constipated. Her cutaneous circulation is lan- 
guid, and her pulse is weak and frequent, beating at the rate 
of about ninety pulsations to the minute. Her skin is cool 
and moist. She has no premonitory symptoms of any kind ; 
the attack comes on suddenly, and disappears in the same 
way. After the paroxysms, she has lately complained of ver- 
tigo and an increased confusion of ideas ; but these phenomena 
have only been present during the last six months. Before 
this, however, she felt quite herself again as soon as she 
regained consciousness, and had no evidences of nervous de- 
rangement after her attacks. Her catamenia have been very 
irregular ever since they were established, which was about 
two years ago. Her hearing is greatly impaired on the left 
side, which may account somewhat for her lack of ready com- 
prehension when addressed. Her tongue is furred, but her 
appetite is good, and she sleeps well at night. 

*' She was directed to take ten drops of a solution of the 
sulphate of strychnia, which contained two grains of the drug 
to the ounce of water, or about the twenty-fourth of a grain 
at a dose, three times a day, and half an hour before meals, 
and to increase the amount by one drop each day until she 
commenced to obtain the physiological effects of the drug, 
when she was to return to the original dose, and again in- 
crease the medicine as before. L. this manner she proceeded, 



EPILEPSY. 231 

and took daily over half a grain before the physiological 
effects of the drug manifested themselves. Together with the 
strychnia-treatment, the galvanic current was applied to lier 
brain and sympathetic nerve every other day, as has already 
been described." 

Instances like the one before ns are frequently met with in 
practice, but they usually fail to impress upon the mind of 
the patient or those around him the grave character of the 
disease from which he suffers. In many cases the attack is so 
slight and so instantaneous, that it may not even attract atten- 
tion, for the reason that the loss of consciousness is of so short 
duration that the continuity of the acts and the ideas of the 
patient is apparently scarcely interrupted ; yet during a few 
seconds he is perfectly unconscious, and there is during this 
interval as complete abolition of sensibility as though he were 
afflicted with the grand-mal seizure. He can be burned, 
pricked with a pin, or otherwise injured, without the slightest 
sensation of pain, and, at the same time, hearing and sight are 
totally abolished. You will, however, generally observe a 
marked pallor of the face, then a fixedness of the eyeballs, 
which is accompanied with a vacant stare. The convei^sation 
of the patient is suddenly cut short, perhaps, in the middle 
of a sentence, and in a second or so he may resume his dis- 
course as if nothing had happened, so that those around him 
are not aware that he has had a fit. In other cases the at- 
tacks are more severe, and the loss of consciousness of longer 
duration ; hence we find present other phenomena besides the 
momentary blank in the mental processes. For example, it is 
not uncommon to find that the patient suddenly drops what- 
ever he may have in his hand, of which we have a good illus- 
tration in the case before us, or, if walking, he may stagger, 
and, if it were not for the speedy return of consciousness, he 
would fall to the ground. You will notice, also, that the pupils 
are dilated ; but you will fail to discover any spasmodic con- 
tractions of the muscles of the face or of any other part of the 
body. In this form of the disease the motor tract does not 
seem to be involved to any appreciable extent, the hemispheres 
appearing to be the organs chiefly affected. It is in these ab- 



232 CLIIS^ICAL LECTUEES. 

sences, or faints, as they are familiarly called, that the mind is 
in time so gravely affected, and hence they are to be regarded 
as a more unfayorable type of the disease than the grand-mal 
seizures. Perhaps the reason of this may be explained from 
the fact that the lighter paroxysms are more frequent, and 
attack the hemispheres with a greater intensity than those of 
the grand mal. 

However this may be, experience has taught us that in 
these attacks the mind sooner or later suffers to a considerable 
degree. As a rule, we do not find, after a paroxysm of this 
kind, any symptoms of nervous derangement ; but occasion- 
ally they exist, as you will recollect they did in this patient, 
who had vertigo and an increased confusion of ideas. Occa- 
sionally you will meet with cases in which the symptoms fol- 
lowing an attack of this kind are as severe in character as 
those after a grand-mal seizure. Tliis young lady's mind has 
now become affected to such a degree, that I do not expect to 
restore it to its original capacity ; for, as you are aware, men- 
tal decay has already taken place, and cannot be entirely 
removed. JSTevertheless, the treatment in her case has been 
successful, and, although she has been under our care sixteen 
months, she has had no fit in the last year ; and, from the 
time that she commenced to take her medicine, her attacks 
have gradually diminished in frequency and severity, until at 
the end of four months they had entirely disappeared, and 
have not since returned. The use of the ophthalmoscope in 
this instance pointed out the therapeutic agent to be employed, 
and the extreme anaemia of the retinal vessels, which existed, 
has been overcome by the use of strychnia, which has the 
power of increasing the amount of blood in the brain and 
spinal cord. She has also had the assistance of galvanism, 
which, when properly applied, produces an analogous effect. 
It will not do, however, to diminish the amount of the medi- 
cine for at least six months. But I shall prescribe for this pa- 
tient phosphorus and cod-liver oil, in addition to the strychnia, 
in order to supply to the brain as much material as it is able to 
take up, and see if in this manner we may not be able to im- 
prove her mental faculties. 

In the diurnal form of epilepsy I have found the bromide 



EPILEPSY. 233 

to act favorablj, while in the nocturnal the strychnia had 
been productive of much more success in my hands than the 
bromide ; however, I place more reliance on the condition of 
the cerebral circulation, as seen by the ophthalmoscope in re- 
gard to treatment, than I do on other indications, and this case 
shows you very well the results of such investigation. 

[XoTE. — After Miss J. F. had continued the use of gal- 
vanism for a year from the occurrence of her last iit, we 
stopped employing it, but she still took the sulphate of strych- 
nia, which she used for about six months longer, and she then 
ceased taking that remedy. The phosphorus and cod-liver 
oil she continued for about a year, and her mind seemed to 
improve somewhat during that time. When last seen in 
June, 1873, she had had no return of the fits for nearly three 
years. 

Her mind had improved very much, in comparison to 
what it was when she first came under our care ; nevertheless, 
it was not what we should expect of a person of her degree of 
education and in her social position. In fact, there was 
marked mental decay. Her general health was good, and her 
emotions were more easily controlled. Her conduct and moral 
character were changed from what they formerly were, but 
not to an extreme degree. Her catamenia were now regular, 
and she had no vertigo. — T. M. B. C] 

The next variety of this affection which I shall bring be- 
fore you here to-day will be that which is called the irregular 
or aborted attacks. 

In these the loss of consciousness is not always complete, 
there being occasionally a kind of semi-consciousness present, 
but in nearly all these patie^its you will find that they retain 
no recollection whatever of what has taken place during the 
paroxysm ; and, even in those instances where they apparently 
recall what has transpired during the attack, it is not at all 
improbable that they have acquired that information from 
others rather than from any distinct remembrance on their 
part. 

Before reading you the histories of some patients which I 



234 CLINICAL LECTURES. 

will presently show you, afflicted wdth this form of epilepsy, 
I wish to point out to you the difference that exists between 
these irregular or aborted paroxysms and a real attack of epi- 
leptic mania, as the former have been, by some authors, con- 
founded with the latter. 

In epileptic mania, properly so called, the paroxysms of 
mental aberration come on subsequently to a true epileptic fit, 
and rarely last but a few moments. In the aborted attacks, 
however, there is no true epileptic seizure which is followed 
by mental aberration, but the irregular paroxysms appear 
rather to take the place of the attacks of true epilepsy. 

Case Y. Epilepsy. Irregular or Aborted Paroxysms, — 
^' T. L., aged thirteen, years, of Jewish descent, was born in 
Xew York City. He has been suffering for four or ^vq years 
from a very peculiar nervous affection which had come on sud- 
denly after a severe fright when he was about eight years old. 
Until this period he had been a very healthy child, and was 
remarkably well nourished. He had an uncle who died of 
softening of the brain, and his grandfather was afflicted with 
paralysis agitans. These paroxysms at first occurred about 
once a month, but they gradually increased until he had one 
every two or three days. His father described them as fol- 
lows : ' My son will be sitting in a chair, when his face will 
become deadly pale ; he will jump up and rush around in the 
most frantic manner, crying and shouting strange words which 
I cannot understand. He does not appear to know what he 
is about. When I speak to him, he takes no notice of what I 
say, although I have always found him to be a most obedient 
boy. He is moody and depressed at times. Sometimes he 
has a strange feeling in his head before the attacks come on, 
as though he was turning round with great speed.' 

"He came under our care during the summer of 1871, 
when he was found to be in the following condition : 

" He was thin, and his countenance was very pale. His 
mind was active, and not at all impaired, and his memory 
was very retentive. In fact, I have seldom seen a more brill- 
iant boy of his age than this young lad. He had no disease 
of the heart or lungs. His pulse was 92, regular, but feeble ; 



EPILEPSY. 235 

liis bowels were constipated, and Lis skin cool. His tongue 
was coated, and liis appetite poor. He frequently had palpi- 
tation of tlie heart. At his second visit he had an attack 
while I was conversing with him. He was sitting in a chair, 
when he said, * I feel it coming, oh ! oh ! ' He immediately 
turned deadly pale, jumped from his chair, and commenced to 
rush around the room, throwing his arms in the air, and utter- 
ing the most agonizing cries ; he then returned to the place 
from which he had started, turned around two or three times on 
one leg, and then sat down and began to cry. His eyes were 
Hxed, and the pupils dilated, but there were no convulsive 
movements present. I pricked him with a pin, but he did not 
move ; I shouted in his ears, but he did not hear ; I held a 
candle before his eyes, but the pupils did not contract, for 
sensibility was entirely abolished. After the paroxysm had 
lasted for about ten minutes, he began to regain his senses, 
but his ideas were quite confused for some little time. He 
did not feel at all stupid after this attack. He said that the 
Reason that he cried out was owing to a strange feeling in his 
head, which was very likely vertigo. I now carefully exam- 
ined his retinal circulation with the ophthalmoscope, and I 
found the vessels anaemic. He has never had any true epilep- 
tic paroxysms. As the attacks had come on during the day, 
he was directed to take a teaspoonful of a saturated solution 
of the bromide of potassium thrice daily, well diluted in water, 
and this amount was gradually increased until bromism was 
produced, which required one hundred and forty grains as a 
daily allowance. As he constantly grew worse, the bromide 
was stopped, and the sulphate of strychnia and galvanism were 
substituted. As soon as the physiological effects of the strych- 
nia began to manifest themselves, the paroxysms decreased in 
frequency, and, after he had been under treatment three 
months, he had an attack about once in three weeks. He 
then left New York, and I have not heard from him since." 

Case YI. Epilepsy. IvTegular or Aborted Paroxysms. 
— " G. ^N"., aged iifty-three years, was born in Ireland, is mar- 
ried, and the father of eight children, all of whom are at the 
present time living. He had for several years been employed 



236 CLIIflCAL LECTUEES. 

as a traveling agent, but lately he lias followed tlie avocation 
of a private watchman. lie has always been temperate in all 
his habits, and enjoyed excellent health until 1861, when an 
accident befell him, from the effects of which he has never 
entirely recovered. He has always been considered a good 
business-man. 

'^ He has a strong hereditary predisposition to diseases of 
the nervous system, as will be seen from his family record. 
His wife has been insane for a number of years. Her father 
and his are cousins-german. A first cousin on his father's 
side, who had been addicted to excessive indulgence in drink, 
died insane, and a second cousin on the same side is at present 
confined in a lunatic asylum. He was, for a number of years, 
prior to his interdiction, in the habit of eating opium. He 
also has a brother who has disease of the brain. 

" IlTevertheless, G. N^. had never exhibited any symptoms 
of mental aberration prior to the year 1861. At this time, as 
he was one day walking up Ninth Avenue, a cornice, which 
was in the course of erection, fell and buried him in its ruins. 
He was taken out of the debris in an insensible condition, and 
carried home. On examination there was found to be a fract- 
ure of the skull, with depression of the left parietal bone, and 
other injuries. He remained in a semi-conscious condition 
for over three weeks, and then he gradually regained his men- 
tal faculties. He now experienced an intense pain in the 
nape of the neck, which was swollen and extremely sensitive 
to the touch. He was unable to speak for nearly a year, not 
because his tongue was paralyzed, for such was not the case, 
as he could move it in all directions with facility, not on ac- 
count of the loss of the memory of words, for he could remem- 
ber perfectly ; his defect of articulation was due to a want of 
coordination in the muscles of the tongue and the lips, so that 
he could not bring them into harmonious action, and conse- 
quently when he commenced to speak, after the lapse of a 
year, his speech was characterized by hesitation and stammer- 
ing, which were at first very conspicuous, but are at present 
hardly noticeable. 

'' For nine months he had a peculiar painful sensation in 
his head, which felt as though the brain rubbed against the 



EPILEPSY. 237 

depressed piece of bone at every pulsation, but at the end of 
this time it disappeared. 

" As soon as he had fully regained consciousness, he was 
again examined, with the following result : 

" There was a general paresis of the body, which was equal 
on the two sides. There was no paralysis of the muscles of 
the face, no deviation of the tongue to either side, and no stra- 
bismus. Tactile sensibility was normal in all parts of his 
body but his neck. His special senses, with the exception of 
hearing, were unimpaired. He had no difficulty in swallow- 
ing, no palpitation of the heart, and his respiration was per- 
fectly normal. He was confined to his bed for a year, and 
duriDg all this time his neck was so sensitive that he could 
not bear the least pressure upon it. He had his head and 
shoulders so supported, however, that nothing could come in 
contact with his neck, and this relieved him from much pain. 
As soon as he was able to sit up, he was sent to St. Luke's 
Hospital, where he was again examined. It was there dis- 
covered that the cervical vertebrae had been dislocated, and 
were partially rotated upon their axes, and this accounted for 
the severe pain from which G. IS", had so long suffered. He 
gradually gained sufficient power to enable him to stand by 
supporting his head firmly between his hands, and his speech, 
which had returned, was marked by great hesitation and stam- 
mering, but this after a while began to improve also. The 
wound from the fracture of the skull had at this time com- 
pletely healed. He remained at this institution for about 
nine months, and at the end of that period he was thought to 
be in a fit condition to be discharged. 

" Two months after the reception of his injuries, while still 
confined to his bed, G. IST. commenced to have fits of absence, 
during which he was perfectly unconscious, but there were no 
convulsive movements observed. These spells came on quite 
frequently, but he did not attach much importance to them, 
as they were of only short duration. 

"In the course of time, however, his disposition, his tem- 
per, and his conduct, became more or less affected in conse- 
quence of these epileptic attacks, and he had a strong desire 
to leave home, which was acceded to by his friends, and he 



238 CLINICAL LECTUEES. 

was consequently sent to St. Luke's Hospital. "While at this 
institution these attacks continued, and he began to notice 
that his memory was very bad, as he was unable to commit 
to memory the hymns which he had been instructed to learn. 
His ideas were every now and then greatly contused, and he 
did not seem to possess the power of concentrating his atten- 
tion. Mental exercise of all kinds seemed to be irksome to 
him, with the exception of writing poetry, in which he seemed 
to take a great interest, although he had never before indulged 
in that kind of occupation. His poetry was of a religious 
character, and some of it was published in one of the daily 
papers of this city. 

" After his discharge from the hospital, he returned to his 
regular avocation, but he was unable to walk much, on account 
of the pain which he had in the neck. Some six months subse- 
quent to this time, he went to a small town in this State for the 
purpose of collecting some money. On arising the following 
morning, he called npon the gentleman and presented to him 
the bill, but he was quietly informed that he had settled with 
him on the preceding day, and on examining his pockets he 
found the money. He then made inquiries in order to find out 
where he had been and what he had done. He was informed 
that he had acted, while at the hotel, in a very strange and 
ungentlemanly manner, shrieking, smashing furniture, crock- 
ery-ware, and every thing that came in his way, for which the 
landlord subsequently charged him well, thinking that he was 
drunk. He had after this left the hotel for an hour or more, 
when he returned to his room and slept till morning. He had 
no recollection whatever of these acts, but during the time 
that he was absent from the hotel he must have settled the 
bill. It has already been stated that Gr. 'N. never drank stimu- 
lants. 

" Since this attack he has had several of these seizures, the 
last one of which occurred shortly before he came under our 
care. He had been very much depressed for some time on ac- 
count of pecuniary losses, when suddenly one day his face as- 
sumed a deadly hue, his eyes had a peculiar appearance, he 
became wild and maniacal, and disappeared from his family. 
When he returned to consciousness, he found himself sixty 



EPILEPSY. 239 

miles from Lome, in a strange place, and lie was perfectly 
unconscious bow lie ever got there. On arriving home he 
discovered that he had behaved in a most disorderly manner, 
and had broken every thing in the room that was within his 
reach, and had then left the house. He must have, during 
this attack, been unconscious several hours. 

" He was admitted to the New York State Hospital for 
Diseases of the I^ervous System, October 31, 1871, when he 
presented the following points of interest : 

'' There exists a well-marked depression of the outer table 
of the skull, situated at the anterior third of the left parietal 
bone. The wound has healed, and there now remains only a 
small cicatrix. The nape of the neck is still very sensitive to 
the touch, and strong pressure causes intense pain. The pa- 
tient holds his head in a fixed position, a little to one side, and 
when walking he steadies it by means of his hands. On in- 
troducing the fingers into the pharynx, the projection forward 
of the cervical vertebrae can be distinctly felt. They are also 
rotated on their axes, as the prominence, which is most mark- 
edly felt on the left side, would tend to show. He complains 
of a sensation in his head as though a tight band were encir- 
cling it. He has vertigo and attacks of unconsciousness which 
are unaccompanied by convulsive movements ; then these mo- 
mentary paroxysms cease, and the aborted or irregular attacks 
take their place. 

" At the present time these epileptic seizures occur about 
once a week. When the lighter attacks come on, he feels 
dizzy, and would fall if it were not for the quick return of 
consciousness. His speech is very little affected, although 
he occasionally stammers, especially when he becomes ex- 
cited in conversation. He is very irritable, and his whole 
emotional system is easily aroused. Trifling circumstances 
seem to cause him great annoyance. His memory is very 
poor, and his intellect is feeble. His pupils are contracted, 
and his eyes have a peculiar vacant expression. The ophthal- 
moscope shows that the retinal vessels are in a congested con- 
dition. His special senses are normal, if we except the im- 
pairment of hearing and the hyperfesthesia which exists at the 
nape of the neck. His bowels are regular, and his urine natu- 



240 CLIT^ICAL LECTUEES. 

ral. Tliei-e still exist a certain amount of paresis on both 
sides of the bod}^, and a giving way at the knees when walk- 
ing, which is quite noticeable. He has functional disease of 
the heart, and on arising in the morning he sufi'ers from pre- 
cordial distress. His lungs are healthy. His tongue is per- 
fectly mobile, and does not deviate to either side. There is no 
loss of the memory of words, but simply slight ataxic aphasia. 
His appetite is poor and his tongue furred. He has had -illu- 
sions and hallucinations, but no fixed insane delusions. He 
had an aborted seizure two days before coming to the hospital. 
He was immediately placed under treatment, which has con- 
sisted in the administration of large doses of the bromide of 
potassium, of which he took a teaspoonful of the saturated solu- 
tion four times a day. As soon as he was fully under the in- 
fluence of the medicine, the amount was reduced to ninety 
grains as a daily allowance. For a period of five months he 
continued to take his medicine regularly, having occasionally 
a slight attack of the lesser seizures, but no aborted paroxysms. 
As he was considerably run down in health at this time, he 
was ordered to take cod- liver oil and the twenty-fourth of a 
grain of strychnia as a tonic, and his bromide was increased to 
one hundred and twenty grains daily. A month later the fits 
ceased, and he had no return of them for seven months. He 
then quit coming to the hospital. At this period his general 
health had improved, and he was able to attend regularly to 
his business, but his mind and memory were still impaired to 
a considerable extent. He seemed, however, to have a greater 
control over his emotions than formerly." 

Case YII. Traumatio Epilepsy. Aborted Paroxysms. — 
" M. C, aged eleven years, was born in [N'ew York City, and 
was a very robust child until she was iiYe years old, at which 
time, as she was one day leaning out of a window, which was 
about eighteen feet from the ground, she lost her balance and 
fell head-foremost, striking violently on the pavement in the 
back-yard. When she was picked up she was found to be in 
an unconscious condition ; she was earned into the house, 
and in the course of about ten minutes she began to vomit a 
large quantity of blood. After this she gradually regained 



EPILEPSY. 241 

consciousness. The same niglit she was attacked with severe 
epileptic convulsions, characterized by complete loss of con- 
sciousness and violent involuntary muscular contractions, lim- 
ited to the right side of her bod3\ These occurred almost 
continuously from six o'clock in the evening until ten o'clock 
the next morning. After the paroxysms had ceased, she was 
found to be completely paralyzed on the right side, including 
the leg and arm. The face was not affected. There was no 
strabismus, but speech was entirely abolished. For two years 
she was confined to her bed before she began to regain suffi- 
cient power to enable her to support the weight of her body, 
and all this time she had an attack of epilepsy regularly once 
a month, which generally took place during the day, although 
occasionally she had an attack at night. 

" These seizures were usually of the aborted variety, and 
were characterized by the following phenomena : The patient 
would become suddenly pale, her eyes had a peculiar expression, 
and she would run violently around the room, laughing in a 
very strange manner. At the end of two or three minutes, with 
a full inspiration, the fit ceased, and she became conscious. 
During the paroxysm the pupils were dilated, and she was 
perfectly insensible to pain. Occasionally, however, she has 
a grand-mal seizure, in which the convulsions are limited to 
the paralyzed limbs. At the end of two years speech began 
to return very gradually, and this was the first sign of im- 
provement which was manifested in her condition. Six 
months after this she was able to walk, although the muscles 
of the leg were very weak. The arm had gained very little 
power during this time. 

" In the summer of 1870 she was admitted into the iN'ew 
York State Hospital for Diseases of the l^ervous System, 
when her condition was found to be as follows : Her mind 
was weak, and her memory much impaired. She was un- 
able to read, and her actions were those of a child four or 
five years of age. Her right arm was atrophied, extremely 
distorted, and possessed of a very small amount of muscu- 
lar power. The right leg was much shorter than the left ; 
and, when she walked, the toes were inverted. Her pupils 
were dilated. At this time she had a fit about once in two or 

16 



242 CLINICAL LECTUEES. 

three months, which was similar in character to the one that 
has already been described. Her general health was good, 
and thcx^e was no defect in her articulation. The treatment 
consisted of twenty grains of the bromide of potassium, three 
times a day, well diluted in water, and the application of gal- 
vanism, three times a week, to the paralyzed limbs. She re- 
mained under our care for over a year, without having any 
iits. Her leg improved, so that she could walk much better 
than formerly, but the arm resisted all treatment." 

It is apparent, from the preceding cases, that there is a 
form of epilepsy in which the patient is unconscious or semi- 
conscious for an interval varying from a few ininutes to 
several hours, during which he performs strange involuntary 
acts, which, as a rule, are not accompanied by clonic convuh 
sions, although, in some instances, these movements may be 
present in a limited part of the body. The attack is never 
preceded or followed by a true epileptic paroxysm, but comes 
on by itself, and appears to take the place of a regular attack. 
Maniacal manifestations may exist for hours or days, and then 
be followed by a fit. There are examples, however, of true 
mania with epileptiform convulsions. I have already men- 
tioned that- the mental aberration in epileptic mania always 
follows the epileptic paroxysm. 

I now come to the consideration of the causes, which I have 
purposely omitted until the present time, so as to group them 
all under one head. These are commonly divided into the pre- 
disposing and exciting. Under the former we include sex, age, 
and hereditary tendency. In regard to sex, I have found about 
an equal proportion of males and females afflicted with this dis- 
ease. The period of life most common for the occurrence of 
epilepsy is between the ages of ten and twenty. Hereditary 
predisposition in this, as in all other diseases of the nervous 
system, is an important element, and I liave found it to exist 
in about one-fourth of all my cases. Of these, the direct epi- 
leptic tendency could be traced in about one-eighth of these 
patients, although this percentage is much larger than that of 
other authors. 

The exciting causes, as described by Reynolds, who has 



EPILEPSY. 248 

made tlie best division I know of, are divided into the psychi- 
cal, the eccentric, general organic changes, and physical in- 
fluences. 

Under the first head we include fright, worry, grief, over- 
work, and the like ; under the second, venereal excesses, onan-^ 
ism, dentition, indigestion, etc. ; under the third, scarlet fever, 
rheumatism, diphtheria, pnenmonia, etc. ; nnder the fourth, 
blows, falls, cuts, and sunstroke. In the seven cases which I 
have enumerated, it will be found that two of these patients 
have a direct epileptic predisposition ; two are descended 
from ancestors who were either insane or had some organic 
disease of the nervous system ; while in three there existed no 
hereditary predisposition whatever. It will, likewise, be found 
that the exciting cause of the paroxysms was as follows : In 
one it was from fright; in two from injuries to the head ; in 
one from scarlet fever ; in one from masturbation ; in one from 
intestinal irritation, caused by eating corned-beef and cab- 
bage ; and in one there was no apparent cause. Among the 
exciting causes, I have found, undue mental exertion, venereal 
excesses, dentition, indigestion, and menstrual derangement, 
most frequent. 

Four of these seven cases were between the ages of ten 
and thirty ; two between twenty and thirty, and one over 
fifty, g.n age at which true epilepsy rarely begins. 

A few words before closing, in regard to the prognosis, 
will conclude what I shall have to say upon this subject at 
present. Hereditary influence, the existence of long intervals 
between the attacks, the disease commencing late in life, and 
marked impairment of the mental faculties, are all to be taken 
into account in giving an opinion, as they are unfavorable in- 
dications. 



244 CLINICAL LECTURES. 



LECTUEE XYII. 

FACIAL KEUEALGIA. 

I PEOPOSE to devote the next two or three lectures to the 
consideration of several neurals^ic or neuralo^oid affections, 
which both from their frequency and obstinacy are worthy of 
careful study. According to the general plan of these lectures, 
I shall not dwell upon the pathology of the diseases. JSTot be- 
cause I have no definite views upon the subject, but for the 
reason that its discussion would lead us away from more prac- 
tical points, and would be necessarily more or less speculative 
in character. 

KEUKALGIA OF THE FIFTH PAIR OF NERVES. 

There are before you three patients affected with neuralgia 
of the face, a form of the affection which is located, or at least 
is manifested, in the sensitive branches of the fifth pair of 
nerves. 

The histories of these cases, prepared by Dr. Cross, give 
you the salient features of three well-marked varieties of facial 
neuralgia — one produced by depressing physical causes, one 
by malarious influence, and the othei' by syphilitic infection : 

Case I. Neuralgia of the Fifth Pair of Nerves, due to 
Ancemia. — " J. H.,- female, aged thirty-one, entered the ]^ew 
York State Hospital for Diseases of the I^ervous System in 
the autumn of 1870. She was the mother of five children, the 
births taking place during a period of seven years. So far as 
she knew, her ancestors had been healthy, but she herself was 
delicate, and had never been robust like others of her near 
relations. She was married at the age of twenty. 

" Being poor, she has been obliged to work at hard manual 
labor in order to maintain herself and children, her husband 
not contributing much to the suj^port of his family. Even 
with all her efforts she has not been able to obtain sufficient 
good and wholesome food to keep her system in a well-nour- 



FACIAL NEUEALGIA. 245 

islied state. She was therefore anaemic, and this was shown 
by her general appearance, and the character of her pulse. 

" At the time of admission she was suffering from intense 
pain on the right side of her face, which was so excruciating 
that she had been unable to sleep for three nights. It came 
on in paroxysms continuing for about an hour, and then a 
remission would take place for two or three hours, when it 
would again increase in severity. At night the pain was 
generally worse than in the daytime. There were no indica- 
tions of her ever having had either syphilis, rheumatism, 
malarious diseases, or gout. It appears, however, that a few 
days prior to the attack she had been engaged in washing in a 
very warm room, and in a state of perspiration had exposed 
herself to a cold northeast wind while hanging out the 
clothes. A short time after this she experienced sharp twinges 
of pain shooting along the course of the ophthalmic branch of 
the fifth pair of nerves, which in the course of a few hours 
extended and involved the superior and inferior maxillary 
branches. After the lapse of three days the paroxysms were 
so severe that she came to the hospital for relief. 

" Her condition was now as follows : Her face was flushed on 
the affected side, and was so sensitive that the slightest touch 
caused her great agony. Her riglit eye was bloodshot, the pupil 
contracted, the eyelids partially closed, and the tears ran down 
her cheeks. The pain at this time was exceedingly sharp and 
lancinating, and during its continuance there were spasms of 
the muscles of the face, with a tendency to close the eyelids. 
Pressure on the two upper cervical vertebrae caused intense 
pain, and over the supra-orbital notch, and the infra-orbital and 
mental foramina, the least touch was unbearable. The left 
side of her face was pale, and the pupil dilated. Her pulse 
was weak and very frequent, her bowels constipated, her 
urine abundant and pale. Previous to this attack she had had 
vertigo and headache, the latter being confined to a small 
spot on the top of the head. There were also noises in the 
ears, and a tendency to drowsiness. She had been troubled 
with violent palpitations of the heart, and had felt very much 
debilitated. She had also had numbness in the tips of her 
fingers, with a sensation as though pins and needles were 



246 CLINICAL LECTUEES. 

sticking into them. In fact, lier condition was that of well- 
marked cerebral anaemia. 

" The primary galvanic current from a battery of twenty 
cells was applied to lier face— the positive electrode containing a 
wire brush being placed on the most sensitive spots of the fifth 
pair while the negative was applied to the two upper cervical 
vertebrae. This application was continued for about twenty- 
five minutes at each seance. In addition she was ordered to 
take cod-liver oil and a tonic compound of strychnine, iron, 
quinine, and phosphoric acid. Her diet was to consist of beef- 
steak, milk and eggs, together with a liberal allowance of bran- 
dy. The next day when she came to the hospital her face was 
greatly swollen, and she stated that the galvanism had relieved 
her considerably. These applications were continued daily for 
a period of three weeks, at the end of which time the neural- 
gia had disappeared. In consequence of her anaemic condi- 
tion, she was advised to continue the tonic remedies and the 
highly-nutritious diet which had been prescribed, in order to 
put. her system in the best possible condition to avoid future 
attacks. Within the last three years she has been three times 
under our care for similar seizures, which were undoubtedly 
due to an anaemic condition induced by poor quality of food 
and too rapid parturition. The treatment in these three at- 
tacks was substantially the same as has already been enumerat- 
ed, and a cure was speedily effected as soon as the tone of the 
system had been improved." 

Case II. Neuralgia of the Fifth Pair of Ner'oes^ of Mala- 
rial Origin. — " C. W., aged twenty-five, entered the hospital 
in the summer of 1871, suffering from excruciating pain in 
the course of the ophthalmic division of the fifth pair of 
nerves. He stated that these attacks came on regularly every 
other day at a certain hour, and, after lasting a variable period, 
ceased. When he began to have them, they occiuTed at about 
four o'clock in the afternoon, but within the last three months 
they have gradually been taking place earlier, so that at the 
present time they commence at about ten o'clock in the morn- 
ing, and last for an hour or more. After the paroxysm he is 
perfectly free from pain for two days, and then it returns with 



FACIAL NEUKALGIA. 247 

renewed yiolence. This fact is to be observed, tliat he never 
lias had an attack at night. He has now been subject to 
tbese seizures for the last six months, and they have gradually 
been getting worse nntil they have become perfectly unendur- 
able. He is conseqnently mucli run down in health, and has 
a well-marked cachectic condition. He has been living in the 
West for several years, w^here malaria is very 23revalent, and, 
although he has not had a well-developed attack of intermit- 
tent fever for eighteen months, he had not been in good health 
for some time prior to the supervention of the neuralgia. He 
had felt weak, his bowels had been constipated, and he had 
had periodic attacks of violent headaches, which, however, 
were of short duration. His tongue was also furred, his ap- 
petite capricious, and his head and hands w^ere at times exces- 
sively hot. 

"These symptoms, after continuing for about a year, and 
which showed that the malarial poison was still active, were 
succeeded by violent paroxysms of neuralgia, of which the 
hgemicrania from which he had suffered at intervals, for nearly 
a year, was merely a lighter manifestation. For the last four 
months he has been taking the sulphate of quinine in doses 
of a grain thrice daily, together with fifteen grains of the 
iodide of potassium. Latterly, however, the doses of these 
remedies have been increased, but there has been no ameli- 
oration in the intensity of the paroxysms. When he came 
under our care the following points of interest were noted : 
There were no indications that he had ever had either rheu- 
matism, syphilis, or gout, but the history of the case, the 
periodicity of the attacks, and the neuralgic pains being lim- 
ited to the ophthalmic branch of the fifth pair, pointed very 
distinctly to a malarial origin. 

" One morning, while we were conversing together, he sud- 
denly pressed his hand against his forehead and commenced 
to walk rapidly up and down the room. He constantly ex- 
claimed : ' It has come again ; can't you give me something 
to stop it, for God's sake ? ' His eye was partially closed, and 
when he removed his hand from his forehead the eyelids 
trembled. There were at first red streaks observable alono; 
the course of the branches of the affected nerves, and in a 



248 CLIIS-ICAL LECTUEES. 

short time tlie forehead, the conjunctiva, and the side of the 
nose, became greatly congested, and he complained of acute, 
darting pain in the eyeball on the right side. The pain was 
especially severe and lancinating at the supra-orbital foramen 
and at the parietal eminence. A moderate degree of pressure, 
however, seemed to afford him marked relief. In the course 
of three-quarters of an hour the paroxysm was over. He 
now complained of noises in his ears, specks before his eyes, 
and vertigo. Examination at this time, by means of the oph- 
thalmoscope, showed the vessels of the retina on the affected 
side to be increased in number, size, and tortuosity. The 
pupil was likewise contracted, and the conjunctiva more or 
less injected. On the left side, however, the pupil was natu- 
ral, and retinal circulation normal. The patient had no 
cough, his heart and lungs were healthy, his bowels were 
constipated, his urine was scanty and high-colored, his pulse 
was 90, but not strong. He had a peculiar yellow hue of 
the skin and conjunctivse, which showed a want of activity on 
the part of the liver. On percussing the spleen, it was found 
to be much enlarged. 

" The galvanic current was applied to the ophthalmic di- 
vision of the fifth pair every day for twenty minutes, in the 
manner that has already been described, in order to relieve 
the pain, and in conjunction, constitutional remedies were 
given to effect a cure. The sulphate of quinine in solution 
was administered, in seven-grain doses, thrice daily. At tlie 
end of five days the physiological effects of the medicine were 
apparent, for the patient was at this period completely cincho- 
nized ; nevertheless the paroxysms did not cease. The sulphate 
of quinine was now continued in large doses for a week, while 
the galvanism was omitted, and the patient during all this 
time grew worse. The pain had become so sharp and lancinat- 
ing that we were obliged to administer hypodermic injections 
of the sulphate of morphia jpro re nata during the parox- 
ysms. The galvanism was again continued, and in place of the 
quinine four drops of Fowler's solution of arsenic were .given 
thrice daily, and this amount was gradually increased to twenty 
drops as a daily allowance, before the neuralgia began to yield. 
After the lapse of a month the patient was free from pain. 



TACIAL NEUEALGIA. 249 

but lie still coBtinned to take four drops of Fowler's solution, 
together with iron, phosphorus, and a highly-nutritious diet, 
for several weeks. A year after he returned home he informed 
us that he had had no relapse, although he is living in a very 
malarious section of the West. He, however, takes his ar- 
senic in small doses as a prophylactic, and it no doubt coun- 
teracts the influence of the miasmatic poison." 

Case III. Neuralgia of the Fifth Pair of Nerves^ of 
SyphilitiG Origin. — " L. ]Sr., twenty -eight years of age ; is 
single, was born in Virginia, and is a merchant by occupation. 
From his childhood he has always been remarkably strong 
and healthy until some seven years ago, when he contracted 
an indurated chancre, which was accompanied by enlarge- 
ment of the inguinal glands on both sides. Subsequently he 
had well-deflned secondary symptoms, such as fever, sore 
throat alopecia, a coppery eruption, especially prominent upon 
the shoulders, back, and chest. From these coppery spots the 
skin was constantly being desquamated in thin, flat scales. In 
the course of a year from the appearance of the chancre, which 
had healed kindly in three weeks, his throat became again 
very sore ; his nose was swollen, and intensely red. These 
phenomena did not yield to ordinary treatment, and he conse- 
quently consulted an eminent surgeon, who on examination 
discovered large mucous patches on the walls of the pharynx, 
at the base of the tongue, on the tonsils, and on the mucous 
membrane of the tip of the nose. He had previously been 
treated for six months with mercury and iodide of potassium 
in moderate doses. 

'' At this period he was placed upon the chloride of gold 
and dilute muriatic acid, while an ointment of the iodide of 
lead was' used freely upon the mucous patches in the nose 
which had already commenced to attack the cartilage. This 
treatment was continued for three months, at the end of w^hich 
time the mucous patches had healed, and he was now advised 
to take a tonic of iron and quinine, as his general health w^as 
much impaired. For a year he was free from any of the mani- 
festations of syphilis, but his throat was still very sensitive to 
the eflects of cold. Soon, however, mucous patches again ap- 



250 CLmiCAL LECTURES. 

pearecl in the throat, which resisted treatment with great per- 
tinacity^ IlN'odes began to form upon the right tibia, and there 
was enlargement of the right epitrochlear gland. He was or- 
dered to take the sixteentli of a grain of the bichloride of mer- 
cury in a wine-glass of cinchona-bark three times a day, and 
the mncous patches were painted every morning with a strong 
solution of chromic acid. It was four months before the ulcers 
healed, nevertheless he continued to take tbe bichloride of 
mercury for some three months longer. 

'' He now formed the habit of drinking whiskey to excess. 
After he had indulged in this babit for several months, he 
received a blow on the right frontal bone, to which he paid 
little or no attention, as the skin was not abraded, and there 
was no sign of contusion. Soon after this he was confined to 
his bed for three weeks from a severe attack of hepatitis, and 
while convalescing from this disease he was seized one night 
with the most excruciating pain in the right frontal region. 
His physician, thinking tbat the paroxysm was due to his de- 
bilitated condition, prescribed morphine in moderate doses, 
together with tonics. Every night when he was warmly en- 
sconced in bed the attack came on with renewed violence, 
and lasted at intervals through the whole night. During tbe 
day, however, there was a remission of the pain and some- 
times complete intermission, while the paroxysm lasted. 

" The patient was totally unable to sleep, and was at pe- 
riods in a highly-maniacal condition. He would roll on 
the floor in agony, uttering loud groans. His face was 
flushed, his pupils contracted, his eyes bloodshot, his skin 
bathed in perspiration, his pulse frequent and small, and his 
appetite greatly impaired. The pain, which at first had been 
confined to the right frontal region, extended so as to involve 
all the branches of the fifth pair on both sides of the face, and 
also the cervico-occipital nerves on the right side. Through 
all these branches sharp, shooting, lancinating pains of the 
most agonizing character flashed during a paroxysm, and, 
although he took from a grain to two grains of morphine 
through the night, it did not afford him great relief. 

" After he had made an ineffectual attempt to commit sui- 
cide, his physician found on examination a large gummy tumor 



FACIAL NEURALGIA. 251 

on the riglit frontal eminence, which was excessive!}^ sensitive 
to pressure. Suspecting its nature, he forthwith administered 
thirty grains of the iodide of potassium well diluted in water 
three times a day, and in the course of a few days the neural- 
gia ceased as if by magic. 

^' Some few weeks subsequent to this attack, the patient 
came to 'New York, and was again seized with acute neu- 
ralgic pains as before. On examination, we found a large 
tumor situated on the right frontal eminence, which was ex- 
cessively sensitive to the touch, but pressure exerted along the 
course of the affected nerves, or on the frontal bone at a short 
distance from the swelling, excited little or no pain. There 
were acute lancinating pains darting along the branches of 
the fifth pair of nerves on both sides of the face, and likewise 
along the branches of both occipito-cervical nerves. The 
patient walked rapidly up and down the room, holding his 
head firmly in his hands, in the greatest distress. His face 
was flushed, his pupils contracted, his eyelids partially closed, 
his hearing morbidly acute, his pulse frequent, and flashes of 
light before his eyes. The tumor was about the size of a 
small pigeon's-egg, and indicated very distinctly the cause of 
his malady. Forty grains of the iodide of potassium well 
diluted in water were administered three times a day, and this 
was rapidly increased to sixty grains before the pain entirely 
disappeared, although he experienced much relief after the 
second day. The tumor still remained, however, after the 
cessation of the neuralgia. 

" In order to eradicate the syphilitic taint which existed 
in this gentleman, and also to remove the tumor, he was di- 
rected to take mercurial baths three times a week, consisting 
of a drachm of the black oxide of mercury, and also to apply 
citrine-ointment to the site of the tumor. After he had taken 
twenty-four baths, the tumor completely disappeared. Tonics 
and the bichloride of mercury were then substituted for the 
mercurial baths, which he took regularly for over a year, since 
which time he has had no paroxysms of neuralgia, although 
he has been troubled exceedingly with boils of a very obsti- 
nate character, which only yielded to the internal administra- 
tion of bichloride of mercury, and the external application 
of citrine-ointment." 



252 CLmiCAL LECTURES. 

These cases very clearly sliow how, in order to treat a dis- 
ease effectuallj, we must ascertahi the cause, and bring our 
therapeutic measures to bear upon it. The first case was suc- 
cessfully managed b^^ tonics, and those general hygienic meas- 
ures which are calculated to improve the tone of the system ; 
very often these will suffice, but it is not to be doubted that 
we can, in many cases, shorten the duration of the treatment 
by direct medication. I have often cut short a severe neuralgic 
paroxysm with a couple of ounces of brandy or whiskey. 

It is in such cases as this first that strong tea or coffee will 
frequently arrest a paroxysm. Guarana, or paullinia, as it is 
sometimes called, acts even more effectually, probably only 
because it is more concentrated, for, when we go back to first 
principles, we find that the active principle of these substances 
is one and the same thing. In such cases there appears to be 
a deficient tone in the coats of the cerebral blood-vessels ; a 
state of passive congestion is thus induced, and this repletion 
of the intra-cranial vessels is an immediate central cause of the 
neuralgia. I have used paullinia in neuralgic headaches for 
the past ten years, and, though I cannot promise you that it 
will do much toward preventing a proclivity to the seizures, 
it is certainly almost always efficacious in cutting short a 
paroxysm due to an anaemic state of the system, and a result- 
ant deficient tonicity in the blood-vessels of the brain. 

A few days ago I was visited by a gentleman who at the 
time was suffering from an attack of supra-orbital neuralgia, 
which he described as atrocious ; so intense was the pain that 
he was at times slightly delirious, and his wife came with him, 
fearful that he was not altogether capable of taking care of 
himself : the general aspect of the patient, the state of his pulse, 
and the ophthalmoscopic examination, all indicated anaemia. 
I told him that I was not in the habit of promising much to 
patients, but that I was disposed to assure him that his pain 
would be gone in half an hour after his taking a dose of medi- 
cine I was going to prescribe for him. As his attacks gen- 
erally lasted two or three days, and he had then only suffered 
for a few hours, he was thankful for the measure of relief I 
promised. He took the fifteen grains of paullinia I pre- 
scribed, and within the half-hom' was entirely free from pain. 



FACIAL ]S"EUEALGIA. 253 

Tlieu, as I have just told you, it not imfrequentlj happens 
that in similar cases immediate relief is obtained from alcohol, 
preferably in the form of one of the spirituous liquors, brandy, 
whiskey, or rum. One dose of an ounce or two in persons 
not accustomed to the use, will frequently cut short an attack. 

It is probable that morphia acts in a similar way, in addi- 
tion to its anodyne influence; and, when it is hypodermically 
injected in the dose of from one-sixth to one-fourtli of a grain, 
an attack of facial neuralgia is often aborted. 

The beneficial effects of electricity are sometimes very 
decided, but it must be confessed that frequently, no matter 
what form of this agent we employ, failure results. Occasion- 
ally, I have found that the application of a very mild primary 
(galvanic) current to the skin and the affected nerve-branches 
gives immediate relief. I have obtained this effect in my own 
case several times, bnt have just as often failed ; but then my 
neuralgia is decidedly malarial in character, and electricity 
is not so beneficial in this type as in some others. 

Of other applications to the affected nerve or its vicinity 
I have not much favorable experience. Liniments are dirty 
and useless ; steam sometimes gives relief, especially when the 
pain is confined to a limited spot. I had recently a severe 
case of nem-algia, occurring in a lady exhausted by purpura 
hsemorrhagica, and which was entirely confined to one eye. 
The application of steam, as it escaped from the s^^out of a 
tea-kettle, always gave her relief in a few minutes. 

Occasionally I have found relief follow the application 
of veratria, especially when the pain is supra-orbital and the 
result of cold. I use it according to the following formula : 
5. Yeratrine, grs. x ; etheris sulph., 3 j ; alcoholi, 3 vij ; M.ft. 
sol. A few drops to be rubbed over the painful parts every 
three or four hours. Hedness and a pricking sensation are 
produi3ed at once, and sometimes the pain disappears after 
three or four applications. 

The bisulphide of carbon, applied in the form of vapor, has 
been recommended ; but, in several trials which I have made 
of it, I have seen no perceptible effect over the pain. Lotions 
of solution of atropia, and of tincture of aconite, cautiously 
used, are sometimes beneficial. 



'254 CLmiCAL LECTURES. 

But, in the facial neuralgia of ansemia, local measures are 
only at best palliative. The affection must be combated by 
general measures, and of these good food, fresh air and mental 
tranquillity stand first. Their good influence may, however, 
certainly be promoted by judicious medical treatment, and 
this ought to consist in the administration of tonics, such, as 
iron, quinia, and others of this kind, and stimulants. The 
special measures I need not again bring to your notice. 



LECTURE XYIII. 

CER^aCO-OCCIPITAL AND INTERCOSTAL NErEALGIA. 

The first case which. I have to present to you to-day is one 
of cervico-occipital neuralgia, so called from its occupying the 
cervico-occipital region, and being chiefly situated in the four 
superior cervical nerves. Of these the great occipital branch 
is the one mainly affected. The history of this case is as fol- 
lows : 

Case I. Cervico-Occijoital Neuralgia, Tfiemnatic in Ori- 
gin. — " K. M., a married lady, forty-five years of age, came 
under our care during the fall of 1871, for a severe pain in the 
bach of the neck, which had troubled her very much for sev- 
eral weeks. It appears that this lady had inherited a rheu- 
matic diathesis, as she had been afflicted for the last twenty 
years with rheumatic pains shifting from joint to joint and 
from muscle to muscle, although she had never had an attack 
of acute articular rheumatism. Her father died of general 
paralysis, and her mother has organic disease of the heart. 

" With the exception of these vague rheumatic pains, she 
has always enjoyed very good health. Two days prior to the 
commencement of the present attack, she was exposed to a 
draught of wind while riding in a railroad-car, which blew di- 
rectly upon the nape of her neck. The next day she experi- 
enced sharp shooting pains in the back of the neck, corre- 
sponding to the occipital and posterior parietal regions. In a 



CEEYICO-OCCTPITAL AND Il^TEECOSTAL NEURALGIA. 255 

few days the pain became so severe that she was unable to 
sleep at night, and for which morphine was prescribed in large 
doses. Wliile rmder its influence she felt very much relieved, 
but, as soon as the effects of the medicine had passed away, the 
pain returned with increased severity, and was not only pres- 
ent in the occipital and posterior parietal regions, but had also 
extended to the inferior maxillary nerve. 

'' On examination, her condition was as follows : There 
were sharp, shooting pains along the nerves distributed to the 
occipital and posterior parietal regions as w^ell as to the neck, 
and along the com-se of the inferior maxillary nerve. These 
paroxysms occurred at various times during the day and night, 
without any regular periodicity. There was marked cutaneous 
anaesthesia in the parts to which these nerves were distributed, 
and this condition was especially manifest wherever these 
nerves became superficial. She could not move her head with- 
out exciting paroxysms of pain, and even gentle pressure was 
sufficient to cause her much suffering. She was unable to 
sleep in the recumbent position without the aid of morphine. 
She had headache, her tongue was coated, her face flushed, 
her bowels constipated, her skin moist, and her pulse full and 
strong. These latter phenomena were due evidently to the 
morphine, which she had taken in large doses. • 

" The treatment consisted in the application of galvanism 
to the affected nerves for half an hour every day — a wire brush 
being attached to the positive electrode, which was passed along 
the course of these nerves, while the negative electrode was 
applied to the nape of the neck. The constitutional remedies 
employed were a mixture of one ounce of the saturated solu- 
tion of the iodide of potassium and half an ounce of the w^ine 
of colchicum-root. Of this she was ordered to take fifteen 
drops three times a day, increasing the dose each day by one 
drop. In the course of two weeks the neuralgia had disap- 
peared, but the patient still continued to take fifteen drops of 
the mixture for about a month. At this time her bowels were 
regular, her tongue clean, her appetite good, and her headache 
had entirely ceased. Within the past two years she has had 
no relapse, although she has had rheumatic pains at intervals 
during this time, which speedily disappeared under the influ- 
ence of the iodide of potassium and the wine of colchicum." 



256 CLINICAL LECTUEES. 

This case aifords a fair illustration of an ordinary attack 
of cervico-occipital neuralgia, and the cause is that which in 
my experience is among the most common. Often the pains 
are not so sharp as in the present instance, but are dull, ach- 
iug, wearisome in character.. Indeed, I think it scarcely if 
ever happens that the pain, in the form of neuralgia now 
under notice, equals that of neuralgia of the fifth pair. 

The disease often shows a tendency to extend ; sometimes 
it goes to the fifth pair ; again, to the lower cervical and dorsal 
nerves ; and, again, to those of the axillary plexus and its 
branches. Or the cervico-occipital region may be involved 
by the extension of the neuralgic disease from other parts, as 
for instance the arm, a case of which is now before you, and 
the history of w^hich I jjroceed to read : 

Case II. OGGijpito-Cervico-Brachial Neuralgia^ of Rheu- 
onatic Origin. — " Mrs. R., aged sixty-five years, was born in 
frermany ; is married, and the mother of several children. Her 
health has usually been good until within the last twelve 
months. For many years, however, she has been subject to 
attacks of subacute rheumatism in different parts of her body, 
which generally lasted a short time, although they caused her 
much annoyance. About a year ago she was seized with a 
dull, aching pain in the right arm, which at first was not very 
severe, but which soon increased in degree, and interfered, to a 
considerable extent, with her sleeping at night. The pain, 
which was at first confined to the right arm, soon extended to 
the occipital and posterior parietal regions, and was so acute 
that she could not move her head or contract the muscles of 
the arm without increasing the severity of the paroxysm. 
She complained of a particularly painful spot on the outer as- 
pect of the right arm. 

''' In the course of two months she found that there were 
numbness and loss of mobility in the affected limb, and, as she 
had been admonished not to use it, in time the loss of power 
became more and more percej)tible, Avhile the pain had not at 
all diminished in intensity. After the affection had continued 
about five months she came under our observation, and her 
condition was then as follows : 



CERYICO-OCCIPITAL AND IIS^TERCOSTAL NEURALaiA. 257 

" Tliere was no liistorj of any injury, or of her ever having 
been subjected to tlie influence of malaria, gout, or syphilis, 
although the evidence of her having had attacks of subacute 
rheumatism was very positive. Her right arm hung helplessly 
by her side, and she was able to raise it only to a very slight 
desrree. She could flex her forearm on the arm and move the 
fingers of the right hand quite well, but the arm itself was very 
greatly restricted in its movements. There were the sensation 
of pins and nieedles in the fingers, numbness and actual diminu- 
tion of tactil-e sensibility in the arm, forearm, and fingers, of the 
right upper extremity. The muscles of the arm, the shoulder, 
and especially the deltoid, were flabby, atrophied, and only con- 
tracted feebly to a very strong Farad ic current. There were 
paroxysms of pain coming on several times during the day and 
night, which were excessively acute and lancinating in charac- 
ter, and were confined to the median and the branches of the 
musculo-spiral nerves in the arm, and the branches of the great 
occipital in the neck. There was one spot on the outer aspect 
of the arm, where the musculo-spiral nerve becomes superficial, 
which was exceedingly sensitive to the touch, while several 
places in the occipital and posterior parietal regions gave acute 
pain on pressure. 

"On moving the upper extremity, there was discovered 
very marked crepitus in the shoulder-joint on the affected 
side, and, when it was forcibly abducted or adducted, there 
was acute pain along the course of the median, musculo- 
spiral, and occipital nerves. The pain was generally more 
severe at night, and came on in paroxysms, which would 
last for an hour or more, and then a complete intermission 
would take place. The muscles were so small and attenuated, 
that the humerus could be distinctly felt throughout its whole 
course. Tliere were no nodes or tumors discoverable on its 
surface. She complained of pain in her head, vertigo, 
and a tendency to somnolency. 

" On examining the retinal circulation by the means of the 
ophthalmoscope, the vessels were found to be small and straight, 
and the choroid rather pale. She was cachectic, and her bowels 
were torpid. At this time she could move her head without ex- 
citing much pain, which had now assumed a dull, aching char- 

17 



258 CLES-ICAL LECTUEES. 

acter. "When the paroxysms of pain came on at niglit, she was 
totally unable to sleep during their continuance ; and it was 
owing to these frequent attacks that her anaemic condition was 
induced, as she had not had any cerebral symptoms until some 
three months subsequent to the onset of the neuralgia. Her 
appetite was capricious, and her tongue furred. Her heart and 
lungs were healthy. The paro*xysms of pain observed no regu- 
lar periodicity, coming on at irregular periods either during the 
day or night, sometimes being acute and lancinating, at other 
times dull and aching, but always sufficiently severe to awaken 
her during sleep. 

" Suspecting the rheumatic origin of the neuralgia from 
the deposit which existed in the right shoulder-joint, the rheu- 
matic diathesis afforded us by the history of the case, the 
numbness and great loss of power, together with excessive 
pain, which had existed for some time prior to the manifes- 
tation of the cerebral symptoms, we gave her a favorable 
prognosis, and immediately put the patient under treatment, 
which consisted in the internal administration of a mixture 
containing a saturated solution of the iodide of potassium one 
ounce, and the wine of colchicum-root half an ounce : of this 
she was to take fifteen drops three times daily, well diluted in 
water — the same to be increased one drop for the doses of each 
day until the physiological effects of the medicine had mani- 
fested themselves. At the same time a strong Faradic current 
was applied to the affected muscles three times a week, and 
along the course of the affected nerves. Under that treatment 
at the end of two months the pain had entirely disappeared. 
She was now placed upon tonics, and, as there were some 
adhesions in the shoulder-joint caused by the deposit, the 
humerus was gently rotated in its socket, and the patient was 
instructed to exercise the arm daily by swinging a small 
dumb-bell. The electricity was still continued. Six months 
after coming under our care she was able to put her hand on 
the top of her head, and to raise her arm to a level with her 
shoulder. The affected muscles had increased in size, and their 
contractility had so much improved that they responded readily 
to a weak Faradic current. Her general health was now excel- 
lent, her appetite was good, her bowels were regular, she had 



CERYICO-OCCIPITAL AND INTERCOSTAL NEURALGIA. 259 

no headache and no vertigo. There had been no return of the 
neuralgia. Such was her condition when she passed from un- 
der our care some three months ago, and since then we have 
not heard from her." 

This case is certainly a very interesting and instructive 
one, and is a good example of many that you are likely to 
meet with. Indeed, I may remark that brachialgia, under 
which term neuralgic affections of the arm are included, is 
almost always due to rheumatism ; a circumstance which does 
not add to their curability. 

ISTow, in the treatment of cervico-occipital neuralgia the 
iodide of potassium is a remedy entitled to prominence, even 
when there is no s)^hilitic taint present. It is certainly true 
that the disease is sometimes a manifestation of syphilis, and 
then, of course, iodide of potassium is the medicine to be em- 
ployed ; but it is almost equally efficacious in the rheumatic 
form of the disease, and its beneficial influence may be in- 
creased by the addition of colchicum. In the cases before us, 
the iodide was given in the form of the saturated solution — 
each drop of which contains about a grain of the salt, and 
with this the fluid extract of colchicum was combined in the 
proportion of one-third. Fifteen drops of the mixture, there- 
fore, contained ten grains of the iodide, and five of the fluid 
extract of colchicum. In both cases the remedy was success- 
ful, for, although electricity was also employed, and probably 
was of service, I am not disposed to regard it as the chief 
agent, or as being any thing more than an adjunct. 

I may also speak favorably of the efficacy of the bromides 
in the form of neuralgia under consideration. Among the 
causes of the disease is anxiety of mind, or excessive mental 
application. I meet with many such cases in my practice, 
and they are generally successfully treated with the bromide 
of potassium, sodium, or calcium, in fifteen or twenty grain 
doses three times a day. My preference is for the latter- 
named salt, as it seems to act more rapidly, more efficiently, 
and with less constitutional disturbance, than the others. 

When the affection is of malarious origin, quinine or arsenic 
will usually effect a cure. I had, a few days ago, a patient 



260 CLIlSriCAL LECTUEES. 

from the interior of this State, who for several months past had 
been suffering from severe pain in the nape of the neck and 
back of the head, which had been regarded as intra-cranial. 
]^ow, it is very difficult in many cases for patients to tell hj the 
sensation whether a pain in the head is situated within the 
skull or in the scalp. They appear usually to be disposed to 
consider it within the cranium, and I often have some trouble 
to convin^je them to the contrary. Physicians are very apt to 
be deceived also in this respect, and hence it was not surpris- 
ing that the patient I refer to was supposed to be suffering 
from severe brain-disease. The suspicion was heightened, both 
in his own mind and in that of his medical attendant, by the 
fact that even moderate mental exertion increased the pain. 
"Well, there is one circumstance which, of itself, is almost suffi- 
cient to make the diagnosis clear, and that is the tenderness on 
pressure, which always exists in cervico-occipital neuralgia when 
the nerves are pressed upon where they are most superficial, and 
indeed, at almost any point of their course both in their roots 
and branches. When to this we add the fact that, in cervico- 
occipital neuralgia, there are none of those significant symp- 
toms — ocular paralysis, aberrations of speech, disturbances of 
motion and sensibility in various parts of the body, convul- 
sions, etc. — which indicate basilar cerebral disease, no one who 
has seen cases of each, or even heard them properly described, 
is likely to be mistaken in their diagnosis. There is a pain in 
the back of the head, nof in the neck, which results from cere- 
bral hyperaemia, but the history of the case, the location of the 
morbid sensation, and the absence of tenderness on pressure, 
will suffice for its discrimination from cervico-occipital neu- 
ralgia. 

But to return to my patient : the pain in the back of the 
neck was severe, and it radiated to the temporo-parietal re- 
gions on each side. The least touch about the posterior 
border of the insertion of the sterno-cleido-mastoid muscle 
was agonizing, and even a breath of air caused great suffering. 
As is usual in the disease, no matter what its cause may be, 
the pain was aggravated by exposure to cold and damp. 

jN'ow, I noticed in this patient that everj^ alternate night, 
at about eight o'clock, there was a slight febrile exacerbation. 



CEEVICO-OCCrPITAL AiN^D Il^TERCOSTAL NEURALGIA. 261 

This was not the case throughout the whole course of the 
disease, but only for three or four nights, as he informed me, 
in a month. I therefore gave him arsenic — he had previously 
taken quinine without effect — in the form of the granules of 
arsenious acid (one-fiftieth of a grain each) one three times a 
day, and had the satisfaction, in which the patient largely 
participated, of seeing him gradually but effectually cured in 
about two weeks. 

Isow, these cases, and the remarks I have made upon them, 
go to show how important it is for you to seek for and ascer- 
tain the cause, for, without a knowledge of that, your efforts 
at treatment will be so many gropings in the dark. Occasion- 
ally you may strike the right course at once, but more fre- 
quently you will blunder on till your patient gets tired of 
you, and tries some other physician, with a more logical mind. 

There is one other case here which, as it also is similar 
to many others you will meet with, I will notice now, 
although the hour is about expired. 

Case III. Intercostal Neuralgia. — " Mary S., aged twenty- 
seven years, is married, and the mother of three children. 
For several months before coming under our care she had 
been very much run down in health. She had had headache, 
vertigo, specks before her eyes, and her appetite had been 
capricious. She had also been greatly troubled with con- 
stipation and felt much debilitated. 

" While in this state she was one night seized with a severe 
pain in the right side, which, prevented her from taking a full 
inspiration. This continued for about two weeks, when she 
came under our observation, at which time she was in the 
following condition : 

" She complained of dull, aching pain in the right side, 
which was greatly increased in severity whenever she took a 
deep inspiration. On examination, her heart and lungs were 
found to be healthy. There were several spots in the course of 
the fourth and fifth ribs which were acutely sensitive to pressure, 
especially over the spinous processes and in the neighborhood 
of the sternum. The pain was constantly present, and did not 
cause her very much distress so long as she kept perfectly quiet ; 



262 CLII^ICAL LECTUEES. 

but, whenever she moved, or made a full respiratory move- 
ment, she suffered exceedingly. She had violent palpitations 
of the heart, which were always increased by exercise or men- 
tal excitement. Her face was pale, her pupils were dilated, 
her pulse was frequent and small, her bowels were constipated, 
her skin was cool and moist, her tongue was furred, and her 
appetite impaired. She generally slept on the affected side 
so as to arrest the movement of the right ribs as much as pos- 
sible. She still complained of headache and vertigo. She 
had no fever, and as a rule slept well at night. 

" An aloetic purge was prescribed to relieve her consti- 
pation, and galvanism was applied daily — the positive pole be- 
ing placed on the fourth and fifth spinous processes, and the 
negative, containing a fine wire brush, drawn along the course 
of the affected nerves for ten or fifteen minutes at esich seance. 
The tincture of the chloride of iron and cod-liver oil were 
given internally, in conjunction with a full, nutritious diet and 
plenty of brandy. In the course of two weeks the pain ceased, 
but the internal remedies were continued for six weeks, so as 
to repair the tone of her system, and she was then discharged, 
cured." 

In regard to this form of neuralgia or pleurodynia, as it is 
sometimes called, I have only time to remark that you will 
find your patients to be rendered much more comfortable by 
the ribs being prevented moving in respiration through the 
application of a broad flannel bandage tightly wound around 
the chest. In this way the overstrained muscles are allowed 
rest, the diaphragm being sufficient to carry on the respiratory 
movements for a few days. 

As an internal remedy I know of nothing better than the 
chloride of ammonium in drachm-doses, dissolved in water, 
and administered three times a dav. 



SCIATICA. 263 



LECTURE XIX. 

SCIATICA. 

We have to consider, to-day, a disease which is unfor- 
tunately very common, and which, from the inconvenience, 
discomfort and intense pain which it produces, is not sur- 
passed by many which it is our province to treat. I have just 
come from a consultation in the case of a gentleman, who, two 
or three days ago, was suddenly seized, while reaching for a 
book on a high shelf in his library, with a severe, sharp, lan- 
cinating pain in the posterior part of the hip and thigh, which 
instantly incapacitated him from moving. He is now stretched 
out on his bed, unable to stir the affected limb by a hair's- 
breadth without suffering the most acute agony. 

This morning, a very honest and intelligent colored man, 
formerly a servant of the Sanitary Commission, and now a 
porter in the custom-house of this city, a strong and well- 
built man, came hobbling into my consulting-room on a 
crutch, scarcely daring to bear the least weight on his left leg, 
his countenance showing how much he suffered at every 
action of the muscles of the affected limb, and all on account 
of this very disease, sciatica, with which he had been suddenly 
seized the day before, two interesting cases of which are now 
before us, and to the histories of which I ask your attention. 

Case I. — '^ L. R., aged seventeen, was admitted into the 
l^ew York State Hospital for Diseases of the JSTervous System, 
in September, 1870. She gave the following history : From 
childhood she had been a very healthy girl until within the 
last three years, since which period she has suffered from a 
painful affection of the left lower extremity, which has caused 
her to lose much flesh. When fifteen years old, she began to 
grow very rapidly, which she has continued to do for the past 
two years. Her father died of a fever some years ago, but 
her mother and brothers are still living, and are in excellent 
health. About three years since, without any known cause, 



264 CLINICAL LECTURES. 

slie was seized at night with a dull, aching pain in the back 
of the thigh. This gradually became worse, and for some 
time was limited to the upper part of that member. After 
a Avhile, however, the pain extended along the nerves on the 
posterior aspect of the leg to the foot, and was of a peculiar 
darting character, and during the paroxysm, which usually 
lasted several hours, she was totally unable to sleep. For 
three years she was subject to these paroxysms, which had 
greatly impaired her health, and oftentimes confined her to 
her bed, and which had resisted the most rigorous treatment. 

" At the time of her admission into the hospital, she was 
examined, and the following points of interest were elicited. 
The left leg was smaller by a third than the right. The muscles 
were atrophied, and their muscular contractility considerably 
impaired. There was marked aneesthesia along the whole 
posterior aspect of the left leg. The limb was contracted, 
the thigh being partially flexed on the pelvis, and the leg on 
the thigh. The leg could be straightened, but the contraction 
of the muscles connecting the thigh with the pelvis could not 
be overcome. She complained of a dull, aching pain extending 
down the back of the leg, which was accompanied by severe 
darting pains whenever she attempted to use that extremity. 
She was obliged to use crutches, for, whenever she bore the 
weight of her body upon the affected limb, it caused her in- 
tense suffering. At the sacral foramina and at the head of 
the fibula there were small, circumscribed spots which were 
markedly hypersesthetic. She was subject every now and 
then to paroxysms of very acute pain, extending through the 
whole of the posterior portion of the leg, which usually lasted 
for two or three days, and then a remission would take place. 

" During these attacks she was confined to her bed, and 
relief was only afforded by large doses of morphine admin- 
istered internally. Changes of temperature seemed to affect 
the paroxysms of pain to a considerable degree. 

" Although well developed, she had lost much flesh, and was 
exceedingly pale ; her pupils were dilated, her lips bloodless, 
and her aspect that of a person who had endured much phys- 
ical suffering. Her appetite was poor, her bowels were con- 
stipated, and she had a short, dry cough which was due to 



SCIATICA. 2b^ 

bronchitis. There was no history of any hereditary taint in 
her family, and, as far as syphilis and rheumatism were con- 
cerned, if either of these diseases existed, they had not yielded 
to either the iodide of potassium or the wdne of colchicum, 
which had been administered in large doses. We commenced 
the treatment with tonics consisting of iron, quinine, strychnia 
and phosphorus, so as to improve the tone of her system, at 
the same time the primary galvanic current was applied to 
the painful nerves regularly three times a week, and, during 
the paroxysms when the pain was so severe as to deprive her 
of sleep, morphine was administered hypodermically pro re 
nata. 

"After the lapse of three months, her general condition 
had improved, and her cough had disappeared. But she w^as 
soon seized with a paroxysm of pain which confined her to 
her bed for two weeks, during which she was treated with large 
fly-blisters applied to the painful spots, and morphia internally. 
Iodide of potassium was after this attack given in gradually- 
increasing doses until she took one hundred and twenty-five 
grains daily. From this remedy she experienced no relief. 
She then took sulphur-baths every other day for a month, 
without any beneficial result. She soon had another attack 
of acute pain, which lasted three days, and from which she 
recovered under the same treatment as before. 

" As no diminution in the frequency of the paroxysms had 
yet taken place, we began the use of deep injections of mor- 
phine, directing the point of the hypodermic syringe so as to 
penetrate the sheath of the sciatic nerve, and injecting therein 
the third of a grain of sulphate of morphia. These injections 
were repeated daily, and by this means we not only obtained 
the effects of the morphia, but also that of acupuncture. The 
quantity of morphine was gradually increased by a minim a 
day until the amount reached three-quarters of a grain daily, 
when she began to experience relief. 

" Besides these injections she was given a full, nutritious 
diet, plenty of brandy, and galvanism was regularly applied 
to the affected muscles and nerves. For four months, three- 
quarters of a grain of morphia was daily injected under the 
sheath of the sciatic nerve, and gradually the neuralgia dimin- 



266 CLIIS-ICAL LECTURES. 

islied in intensity until it finally disappeared. Whenever 
these injections were omitted, as they occasionally were, she 
was subject to paroxysms of pain ; after this the quantity of 
morphine was gradually diminished by one minim a day, 
until the amount was reduced to -B.ye minims, when the 
remedy was discontinued. Her general health, since the 
pain had ceased, had rapidly improved, her appetite was 
good, her sleep regular, and she could walk without the aid 
of crutches, perfectly free from pain. The muscles and the 
diseased side had increased so that the circumference of the 
affected leg was nearly as great as that of the other. 

" There, however, remained a contraction of the thigh on the 
pelvis which could not be overcome, although the contraction 
of the leg on the thigh had yielded to the use of galvanism. 
In order to remedy the former, we advised a surgical operation, 
to which she would not submit, and on that account one leg 
was apparently shorter than the other, so that in walking she 
had the gait of a person suffering from infantile paralysis. 
After the injections were discontinued, she remained at the 
hospital for three months, during whicb galvanism was applied 
to her leg regularly every other day. She was then discharged 
cured, and a year afterward she stated that she had had no 
return of pain." 

Case II. — "J". I. R., forty years of age, was born in 
the United States; is married, and a stage-driver by occu- 
pation. He has always been temperate in his habits, and has 
never suffered from any disease since he was ten years old, 
until the beginning of his present trouble. From the character 
of his occupation, he has been continually exposed to all kinds 
of weather, and his being confined to a narrow, hard box on the 
top of the stage, and constantly riding over the rough pave- 
ment, has no doubt been influential in producing the severe 
neuralgia from which he now suffered along the course of the 
right sciatic nerve. 

" This pain began about two years and a half ago in the 
region of the sacral foramen, and seemed confined to a small 
area in this situation, which was acutely sensitive to press- 
ure. Being obliged, however, to continue his occupation, he 



SCIATICA. 267 

found that he could not rest the weight of his body upon the 
right side of his nates, without exciting severe suffering. He 
still attended to his duties for two weeks longer, and then he 
was obliged to desist on account of this pain, which had now 
extended into the calf of the leg, which was swollen, and so 
painful, that he could not move the limb, as the least muscular 
exertion served to increase his suffering. 

^' For five months he had endured these paroxysms, which 
occurred at irregular intervals almost daily, without obtaining 
any relief; at the end of this time he applied for admission 
to the ISTew York State Hospital for Diseases of the JS'ervous 
System, when he was in the following condition : He was able 
to walk by means of a cane, but not without much phys- 
ical suffering, which was excited whenever he attempted to 
bend the leg on the thigh or the thigh on the pelvis ; conse- 
quently he kept his leg straight, dragging the foot along on the 
ground when walking, so* as to avoid bending the knee. The 
right leg was smaller than the left, but there was only little 
atrophy and the muscles responded readily to a moderately 
strong Faradic current; not, however, without exciting pain. 
The whole posterior aspect of the leg was in a state of hyper- 
sesthesia, which was particularly marked over the sacral 
foramen, and above Poupart's ligament there was a very 
sensitive spot. He frequently complained of sharp electric 
pains in the cutaneous branches of the sciatic nerve, which, 
were of frequent occurrence, and took place generally during 
the day, although occasionally they were present at night, 
and then he was unable to sleep. He was thin, his appetite 
was impaired, his tongue was coated, he felt much debilitated, 
and was sometimes troubled with diarrhoea. 

" The treatment consisted in a deep injection of the one- 
sixth of a grain of the sulphate of morphia into the sheath of 
the affected nerve, and this amount was gradually increased 
by a minim a day until the quantity was augmented to half 
a grain. Tonics were administered internally, and galvanism 
was applied to the nerves and muscles on the diseased side. 

" After the lapse of three months, under this treatment, 
the pain had ceased, and then the amount of morphine was 
gradually diminished. Six months from the time of coming 



268 CLINICAL LECTUKES. 

under our care he was discliarged, but he has subsequently 
returned twice to the hospital within the last two years for 
similar attacks, which yielded to the deep injections of large 
doses of sulphate of morphia. 

" At the present time he is perfectly free from pain, and is 
able to use his right leg very well without the assistance of 
a cane. JSTevertheless, it is not as strong as it formerly was. 
Whenever he takes moderate exercise he iinds that the mus- 
cles of the right lower extremity soon become fatigued, and, 
after he has been walking an unusual amount, his leg is weak 
and stiff for several days. His general health is, however, 
good, his appetite is excellent, he sleeps well, he has gained in 
weight twenty pounds, and has not had a paroxysm of pain for 
over six months." 

You will observe that, in both these cases, the disease was 
not of such sudden onslaught as in those to which I have al- 
luded, and I think it is usual for it to begin in this somewhat 
gradual way ; still its progress is always rapid enough, the full 
height being generally reached in a few hours. 

A patient who has once had an attack becomes thereby 
more liable to others. The nerve, after the full force of the 
disease is spent, remains in a more or less irritable state, -during 
which it is particularly liable to a fresh outbreak, and, even 
when this does not occur, it is quite common for the patient to 
be reminded, on any little extra exertion or exposure to cold, 
that he has a master ready on the least sign of rebellion to put 
the screws to his refractory subject. Sometimes, even when the 
patient remains perfectly still, there are sharp, shooting, elec- 
tric-like pains in the affected limb, and which follow the course 
of the sciatic nerve and its branches. Occasionally there are 
involuntary muscular twitchings, which may be so extensive 
as to involve the whole limb. 

You will infer, from these histories and remarks, that 
sciatica is a neuralgic affection of the sciatic nerve and its 
branches. I am inclined to think such an inference would be 
correct, and yet I am not quite sure that sciatica is a true 
neuralgia. It certainly is neuralgoid, but the sudden way in 
which it sometimes makes its appearance, as well as the gen- 



SCIATICA. 269 

era! course of the disease, gives some warrant for the opinion 
that sciatica is not exactly neuralgia. But, as we have no 
precise idea as to what neuralgia is, the discussion of the ques- 
tions of the relations of sciatica to it is perhaps rather prema- 
ture. What we do know is, that sciatica is a painful affection 
of the sciatic nerve, analogous in its main characteristics to 
neuralgia, and that must suffice us for the present. 

Careful observation of the disease shows — and indeed, if you 
pay even moderate attention to the complaints of your patients, 
you will find — that there are some points where the pain is more 
acutely felt than at others. These, as in cases of pure neural- 
gia, correspond to the points where the nerves are most super- 
ficial, or where they are in contact with a hard resisting medi- 
um such as bone. Thus, in sciatica, we find the painful 
points on the skin to be those which correspond to the sacral 
foramina where the large and small sciatic nerves emerge from 
the pelvis, a series corresponding to the emergence of cutane- 
ous branches through the fascia, a fibular point at the head of 
the fibula, an external malleolar, and an internal malleolar. 

As far as the causes of sciatica are concerned, you have 
had some of them already indicated to you in the remarks I 
have made, and in the histories of the cases before you. In 
addition, it may be induced by an enlarged prostate gland 
pressing on the nerve, tumors of the abdominal organs, hard- 
ened Iseces in the colon, the foetal head in childbirth, and by 
pressure on the nerve at any part of its course, as it passes 
down the back of the thigh. 

The diagnosis is not likely to prove a serious matter with 
you, and scarcely calls for special consideration at this time ; 
and the prognosis is not serious ordinarily unless the cause is 
of such a character as to be difiicult or impossible of removal. 
In the treatment of sciatica almost every agent capable of 
directly relieving pain, and many others, which have been sug- 
gested from theoretical .considerations of the nature of the 
disease, have been employed, -y^ith varying success. I have no 
intention of wearying you with them, but will briefly give 
you the ideas which no small amount of experience has caused 
me to form on the subject : 

One point, however, about which there is no difterence of 



270 CLrNlCAL LECTUEES. 

opinion, is, that, if there is any agent exerting a mechanical 
effect on the nerve, such as a tumor, for instance, of any kind, 
it must be removed before you can expect any permanently 
beneficial result. You may relieve the pain temporarily with- 
out removing such a cause, but you will not cure the disease. 

My experience has convinced me that no direct effect is 
to be produced in cases of sciatica by constitutional means of 
treatment, except in those cases which have a constitutional 
origin. These are the malarial, the rheumatic, and the 
syphilitic cases. In the first, quinine, but I think preferably 
arsenic, will be of great service ; in the next colchicum is gen- 
erally advantageous ; while, in the syphilitic cases, iodide of 
potassium must be given with or without mercury, according 
to the length of time which has elapsed since infection. "When, 
as sometimes happens, sciatica occurs soon after the origination 
of a chancre, mercury may be administered with advantage, 
but, if several years have elapsed, I prefer to give the iodide 
alone. 

As to local means of treatment — and they should be em- 
ployed even when there is a constitutional cause — there are 
two agenta which are preeminently useful, and these are mor- 
phia hypodermically administered, and the galvanic current. 
The first should be given in gradually-increasing doses, and I 
prefer for this purpose the solution recently recommended by 
Dr. Lawson, in his little work on Sciatica, of morphias muriat., 
or (as we generally use in this country) sulphatis grs. x, aquae 
destil. 3 ij, M. sol v. This solution is partially solid at ordi- 
nary temperatures, and must be warmed before administration, 
so as to cause complete solution of the separated crystals. 
Every six minims of this contain one-half of a grain of mor- 
phia. Two minims, equivalent to one-sixth of a grain, are 
sufficient for a first injection, and this may be gradually in- 
creased, if necessary, to half a grain. One injection a day is 
generally sufficient ; two, however, may be necessary in ex- 
treme cases. Dr. Lawson carries the point of the syringe to 
the depth of an inch or an inch and a half, without regard to 
the nerve, further than that he recommends that the injection 
be given in its neighborhood. I prefer to strike the nerve 
with the point of the syringe, and then to inject. To do this 



SCIATICA. 271 

is no difficult matter. Select a point on the posterior aspect of 
tke thigh about four inches below the trochanter major of the 
femur, and an inch exterior to the median line ; push the point 
of the syringe perpendicularly, and with no great haste, and, 
at a depth varying from one to two inches, you will strike the 
nerve. You will know this by a slight thrilling sensation, 
passing down the patient's limb. All you have to do now is 
to inject and withdraw the syringe. If you do not strike the 
nerve, it is better nevertheless to administer the dose rather 
than to try again, or to move the point of the syringe about 
in the attempt to find the nerve. Even if you miss it at first, 
a little experience will soon enable you to hit the nerve every 
time. To save pain and apprehension on the part of the 
patient, it is better to render the skin anaesthetic by the ether- 
spray. The effects of this treatment are generally very de- 
cided at once. I have had patients, who walked with the 
utmost difficulty, leave my consulting-room with an elastic 
step and free from pain a few minutes after using such an 
injection as I have described ; and others, who could not even 
turn in bed or move the aifected limb, get up and walk about 
the room after a like period. The pain, however, returns, and 
the injection must be repeated, and in slightly larger doses. 

But the treatment is not only palliative, it is often posi- 
tively curative. Dr. Lawson himself was permanently cured 
by it, and many cases within my own experience have been 
equally successfully treated. Several of them, those of you 
who attend the clinics of the l^ew York State Hospital for 
Diseases of the Nervous System have seen for yourselves. 

I do not wish you to understand that Dr. Lawson devised 
this treatment. It was practised long before he wrote on the 
subject, and I have used it for several years. Both the cases 
before you were treated by it two years before Dr. Lawson's 
observations were published. But to him is to be ascribed 
the credit of recommending a strong solution, and thus dimin- 
ishing the quantity of fluid injected, and of insisting upon 
the great value of the method more strenuously perhaps than, 
had any one before him. 

The next method of treatment which is to be regarded as 
decidedly beneficial in sciatica is electricity. My experience 



*2T2 CLINICAL LECTUEES. 

has convinced me that the Faradic current does no good. On 
the contrary, by stimulating the muscles to contract, it in- 
creases the pain in the nerve and its branches ; having, there- 
fore, the same effect as voluntary movements of the limb. 
But such is not the case with the primary or galvanic current 
when applied, as it ought to be, so as to pass equally and con- 
stantly through the nerve. One sponge may be placed on the 
back at the junction of the sacrum with the os innominatum 
or lower, over the point of exit of the sciatic nerve from the 
pelvis, and the other in the popliteal space, or higher upon the 
posterior face of the thigh. As strong a current as the pa- 
tient can bear should be used. 

I prefer, however, to pass the current directly through the 
nerve by means of needles introduced down to its sheath. 
These needles should be insulated except at their points, and 
then, being attached to handles which can be brought into 
communication with the battery, are rapidly passed with a 
rotary motion down to the nerve. I generally select a point 
at the upper part of the posterior aspect of the thigh for one 
needle and a point two or three inches below for the other. 
Two or three of Hill's cells will furnish a current of sufficient 
intensity. I have several times succeeded in breaking up a 
paroxysm of intense sciatica, and effectually curing the patient 
by a single application, but usually several are required. I 
have never witnessed the least untoward result from the use of 
galvanism in this way. 

Another useful means of treatment consists in the employ- 
ment of repeated blisters. These should be made long enough 
to reach the whole length of the thigh, and should be three or 
four inches wide. One will often give great relief, and two 
or three will sometimes effect a cure. But they are not to be 
compared in efficacy to the measures I have mentioned. 

As to ergot and other internal remedies which have been 
suggested under the idea that sciatica is a disease of the cord, 
I have not much to say. Certainly pains along the course of 
the sciatic nerve are often relieved b}^ ergot, but then every 
pain in the sciatic nerve is not sciatica, and those pains in it 
which result from special diseases are very different in charac- 
ter, and have a very different clinical history, from that affec- 
tion of the nerve which we call sciatica. 



OEGAIS^IC INFANTILE PAKALYSIS. 273 



LECTUEE XX. 

ORGANIC mrANTILE PARALYSIS. 

This affection, as its name implies, is essentially a disease 
pf childhood, and it particularly claims your earnest attention, 
not only on account of the frequency with which you will 
meet with cases in practice* but also owing to the great dif- 
ficulty which you will experience in effecting a cure, if you 
do not appreciate the gravity of the affection, and begin 
early an appropriate treatment. There is a prevalent idea 
that nothing can be done to arrest the course of this disease, 
and hence it is that cases, which would be at an early period 
amenable to treatment before the beginning of muscular atro- 
phy, are neglected, and consequently, when brought under ob- 
servation, exhibit evidences of having existed for a lengtli 
of time, such as the decrease in the size of the limbs, the great 
loss of electric contractility, and the marked changes of fatty 
degeneration which the muscles are seen to have undergone 
when we come to examine their fibres under the microscope. 
ITot only, in severe cases, do we discover these phenomena, 
but we also find a considerable decrease in the temperature 
of the affected limbs, which become cold and bluish, owing 
to a want of proper circulation. Then in time follow distor- 
tions of various kinds, according to the degree of the paralysis 
of the different muscles, for it must be remembered that, 
however extensive the paralysis may have been in the be- 
ginning, in the lapse of a few weeks or months the general 
paralytic effects begin to subside, and after a while there re- 
mains only a local paralysis which is confined to either one 
or more extremities, a group of muscles or a single muscle, as 
the case may be. 

We find very early in the course of the disease that the 
electric contractility of the affected muscles is considerably 
impaired, and in some cases abolished, to the stimulus of the 
Faradic current, even before we can discover any signs of 
atrophy. When, however, atrophy has once begun, the elec- 

18 



274 CLIiS^ICAL LECTURES. 

trie conti-actility disappears in proportion to its progress ; so 
that in a few months it is entirely lost, and then we discover 
that tlie patient is unable to exert his power of will over these 
ninscles, and that the galvanic current is powerless to excite 
contractions. We also perceive that certain muscles in the 
same patient have their electric muscular contractility im- 
paired in different degrees : for example, when the affection is 
recent, you will notice that certain muscles respond to a weak 
Faradic current, while others are only called into activity by a 
powerful galvanic battery. From this circumstance we infer 
that the former muscles will regain theii' normal condition in 
a short space of time, whereas the latter will require months 
and perhaps years to restore them to their normal integrity. 

One point I wish to impress particularly upon your minds, 
and that is, that this disease primarily is a paralysis and not 
an atrophy. The atrophy is a secondary result, which takes 
place on account of deficient nutrition, in consequence of the 
impaired function of the spinal cord, so that a smaller amount 
of blood is sent to the affected muscles than to their corre- 
sponding healthy members. Owing to these changes in nutri- 
tion, the muscular fibres are absorbed or else replaced by fat. 
When this process of fatty degeneration has progressed to 
such an extent that we are unable to produce contractions 
by means of a powerful galvanic battery, there is nothing to 
be expected in the way of treatment, as the case is absolutely 
hopeless. Before making any further remarks, I desire to 
read to you the following histories, which will aptly illustrate 
many of the symptoms of this disease : 

Case I. Organic Infantile Paralysis. — " Lizzie W"., a 
pretty, robust-looking little girl, of about six years of age, 
came to the New York State Hospital for Diseases of the 
Nervous System, in the month of August, 1870, to be treated 
for a paralysis of the light lower extremity, which had existed 
for over a year. The affection had developed itself very 
suddenly in her case. She had complained of pain in her 
back, and had had some febrile symptoms during the day, but 
no particular importance was attached to these phenomena. 
The next morning the nurse found that the little girl did not 



ORaANIC mFAE^TILE PARALYSIS. 275 

arise at her accustomed hour, and, on going to ascertain the 
cause, she perceived that she was paralyzed in all four of her 
extremities to such an extent that she was unable to move. 
For two weeks she was perfectly helpless, and then her left 
lower and both her upper extremities began to improve, 
and they continued to do so gradually during six months, 
when they were apparently restored. The right leg had re- 
gained sufficient power, at the end of a month, to enable her 
to walk, but soon after this it began to diminish in size, and 
was very cold to the touch. Friction had been resorted to, to 
restore the impaired mobility, but with little or no success. 

''When admitted to the hospital, L. W. was in good gen- 
eral health. Her bowels were regular, her tongue was clean, 
her skin was cool, her pulse was natural, her appetite was ex- 
cellent, and her sleep was sound. Her heart and lungs were 
healthy. 

" There was no paralysis of the upper extremities, nor of 
the left leg. These members were warm, well nourished, and 
apparently strong, although they may have been weaker than 
they formerly were. The right leg and thigh were small, on 
account of the atrophy of the muscles, and very cool to the 
touch. The skin was livid, and its circulation impeded. 
The toes hung down to an extreme degree, whenever the pa- 
tient raised her foot from the ground. The power of the will 
over the diseased muscles was diminished, but not abolished, 
as she could still bring them into action by a strong effort of 
volition. The tactile sensibility was normal, although the 
reflex excitability was entirely destroyed. The temperature 
of the right leg was several degrees below that of the left, as 
was ascertained by means of a delicate thermometer. The 
right leg was about half an inch shorter than that of the left, 
and this, combined with the paralysis, and the impairment of 
the voluntary power over that extremity, gave to the patient 
a very characteristic gait, which is better appreciated when 
seen than when described. 

" On applying a strong Faradic current to the affected mus- 
cles, no contractions of their fibres were observable in any part 
of the leg, although at the upper portion of the thigh the mus- 
cles responded feebly. A primary galvanic current of forty 
cells produced slight contractions in all the diseased muscles 



276 CLIJS^ICAL LECTURES. 

excepting the tibialis anticns, which required the full force of 
a fifty-cell battery to cause it to act, and even then the fibres 
contracted very slightly. Specimens of the different diseased 
muscles were obtained by means of Duchenne's trocar, and 
carefully examined microscopically. Oil-globules were dis- 
covered in all, and the transverse striae were very faintly 
visible in the fibres of the tibialis anticus, while they were 
more or less indistinct in all those muscles whose electric 
contractility was greatly impaired. In the thigh, however, 
at the upper third, the muscles appeared to be in a perfectly 
normal condition. 

"This patient's treatment consisted in the daily application 
of the primary galvanic current, one pole being placed upon 
the back above the seat of the disease, and the other applied 
to the fibres of each muscle, so as to bring them all into action. 
After all the diseased muscles had been thus thoroughly gal- 
vanized, the mother was instructed to knead them daily, even 
to the extent of exciting pain. An hypodermic injection of the 
one-fortieth of a grain of the sulphate of strychnia was given 
every other day. At the end of a year all the muscles of the 
right leg excepting the tibialis anticus responded better to a 
strong Faradic current than to the galvanic, and consequently 
the former was substituted for the latter. After the lapse of 
eighteen months, during which the treatment was strictly fol- 
lowed, the patient could walk well. The two legs were nearly 
equal in size, but there remained paresis of the tibialis anticus 
accompanied with dropping of the foot, and a quarter of an 
inch of shortening in the right leg. As far as could be learned 
there was no hereditary predisposition to diseases of the ner- 
vous system in the family, and no apparent exciting causes 
could be assigned for the attack." 

Case II. Organic Infantile Paralysis. — " A bright boy, 
four years of age, came under our care at the latter part of the 
year 18Y0, for paralysis of the lower extremities and the right 
arm. It seems that some two years ago his mother discovered 
that he did not use his legs and arm with his customary vigor ; 
but, as he had never learned to walk, and had been intrusted 
almost entirely to the charge of a nurse, she could not state 



ORGANIC INFANTILE PARALYSIS. 277 

liow long the affection liad lasted before it was noticed. The 
nurse informed us, however, that the child had been restless 
and very fretful for a few days prior to the discovery of the 
paralysis, and she was quite sure that the disease had come 
on very rapidly. This boy had nursed until he was eighteen 
months old, when he was weaned. For some time after this 
he was troubled with diarrhoea, and lost flesh considerably 
during several weeks. 

" Prior to this attack, however, he had been remarkably 
well. After he was paralyzed, he could move both his legs 
and arm to a slis^ht des-ree, and for three or four months he 
appeared to improve somewhat, but his limbs began to waste 
in the course of time, and became cold to the touch. He had 
never learned to walk, nor even to support the weight of his 
body upon his legs. 

" When we first saw^ him his condition had by no means 
improved. His right arm hung by his side, and, although he 
was able to give it some voluntary motion, it was in reality 
nearly useless. It was almost an inch shorter than the lef% 
its muscles were greatly atrophied, and its strength so much 
impaired that the child could not raise it from his side or grasp 
an object with his hand, and retain it. He could move the 
fingers to a slight degree, through a strong effort of the will. 
There was a tendency for the fingers to contract into the palni 
of the hand, which showed that the extensor muscles were the 
most affected. The deltoid appeared to be equally involved 
with the other muscles of the right arm. The legs, like the 
arm, were greatly atrophied, and were some five degrees below 
the temperature of the left arm. The child could not stand 
without support ; in fact, he could not use his legs with any 
better success than he could his affected arm. He had to be 
carried about, wherever he went. 

" The tactile sensibility and the sensibility to pain were un- 
impaired. The reflex excitability was somewhat diminished, 
although not entirely destroyed. A strong Faradic current 
was incapable of exciting the diseased muscles into activity, 
although forty cells of a very powerful galvanic battery pro- 
duced feeble contractions. The peronei and the tibialis an- 
ticus muscles in both legs were greatly weakened, and caused 



278 CLINICAL LECTUEES. 

a certain degree of distortion, which might be appropriately 
called talipes equino- varus. There was no trouble with his 
bladder, his bowels were regular, his appetite was good, and 
his general health was excellent for one in his helpless state. 

"As soon as we found that the diseased muscles responded 
to galvanism, we pronounced the case favorable, and imme- 
diately began the treatment by making an application of 
galvanism sufficiently strong, to the diseased muscle every 
other day, to cause contractions without regard to the degree 
of pain. Of course, the pain which the patient suffered was 
necessarily great, as the sensibility was intact. An hypodermic 
injection of the one-sixtieth of a grain of the sulphate of 
strychnia was employed every alternate day, and gradually 
increased ])ro re nata. Small doses of phosphorus were also 
administered internally. 

"After remaining under treatment a year, the patient 
could walk, but the deformity of the feet still remained. The 
peronei and tibialis anticus muscles were still very weak. 
His legs had, however, increased considerably in size, and he 
could manage to progress with a rather hobbling gait. His 
arm had likewise improved very gradually, he could raise it 
from his side, and use the hand for movements which were 
not YQYj complex in character, but not with facility, and it had* 
likewise gained in length, from the persistent application of 
galvanism, over half an inch. As all the muscles now con- 
tracted under the influence of a Faradic current, his mother 
determined to proceed with the treatment herself, and he ac- 
cordingly passed from under our observation relieved, but 
not cured. The result of this case has not yet been ascer- 
tained." 

As in the examples which I have just read, the symptoms 
of organic infantile paralysis are generally pretty quickly 
developed, and as a rule careful investigation will usually 
reveal their existence in the great majority of cases, although 
sometimes no phenomena whatever are observed, they being 
so slight as to pass unnoticed, until suddenly the nurse 
or the mother discovers some time afterward that the child 
does not use its limbs in creeping, or in making other move- 



OEGANIC mFANTILE PAEALYSIS. "279 

ments. This failure to distinguish the disease is most apt to 
occur in the cases of very young children where the paralysis 
is confined to the lower extremities ; because these members 
are not used, comparatively speaking, to the same extent as 
the arms, before the child has learned to walk ; and conse- 
quently, when the legs are paralyzed, they do not attract the 
attention of the nurse or parents. 

The disease is usually, however, ushered in by well-marked 
phenomena of febrile excitement, which consist in increased 
temperature of the skin, acceleration of the pulse, inability 
to sleep, restlessness, and a general peevishness of disposition 
which cannot be controlled. The tongue is coated, and, if the 
child be suflBciently old to express his feelings, he may com- 
plain of a dull, aching pain in the back, which marks the limit 
of the disease in the spinal cord. After these symptoms have 
lasted a few days, the paralysis is usually fully developed ; 
sometimes, however, the affection begins suddenly with con- 
vulsions. 

There soon appears a marked diminution in the tempera- 
ture of the affected limbs, which is easily ascertained from the 
first by means of a very delicate thermometer, and which as 
time elapses becomes very apparent to the touch. This devia- 
tion of temperature is always present, and is at times so ex- 
treme that the thermometer will indicate a difference of as 
many as ten degrees between the diseased limbs and the cor- 
responding healthy ones, although you will ordinarily find 
that the decrease in temperature is not over four or five 
degrees. The tactile sensibility and the sensibility to pain are 
generally normal, although in some few cases you will dis- 
cover a slight impairment, but this is the exception rather 
than the rule. The reflex excitability, however, is more com- 
monly affected ; sometimes it is abolished even from the very 
commencement of the disease, and at other times it is dimin- 
iehed, so that when you tickle the sole of the foot, for in- 
stance, the patient will make an attempt to withdraw it, but 
by no means with that degree of vigor that he would manifest 
if his spinal cord were in a perfectly healthy condition. 

Before long, evidences of impaired nutrition show them- 
selves in the affected extremities, such as you see in this little 



280 CLINICAL LECTUEES. 

girl, whose right leg is small, and badly supplied with blood. 
You will observe the livid hue of the skin, and jou will notice, 
when I press it strongly with my finger, that it is some time 
before the color returns to the compressed surface. All this 
points to a sluggish condition of the venous circulation. 

In time atrophy supervenes in the paralyzed limbs, and 
this degeneration after it has once begun usually pursues 
a very rapid course, and, jpari passu with the atrophy, the 
electric contractility of the muscles is still further diminished ; 
and hence it is that, when the muscles have become greatly 
degenerated, we are able to produce either slight contrac- 
tions, or none at all, by means of the induced or galvanic 
currents. For you must remember that the electric contrac- 
tility is generally impaired before the supervention of the 
atrophy, in the same manner that it is in other kinds of paral- 
ysis. When speaking of diseases of the spinal cord accom- 
panied with paralysis, I believe I told you that the electric 
contractility was almost always more diminished in them 
than in those of cerebral origin. After the atrophy has com- 
menced and the transverse strisB have begun to disappear, there 
of course must come a time when the muscular tissue is con- 
verted into oil-globules and fat- vesicles. If we remove a small 
piece of the affected muscles from a patient at this stage of 
the disease, by means of the little trocar invented by Duchenne, 
and examine it carefully under the microscope, we shall find 
that the transverse striae are either very indistinct, or are en- 
tirely absent, that the fibrillse are irregular and loose, and that 
oil-globules and fat- vesicles are seen in abundance. But in 
every patient you will not discover structural changes in the 
muscles, even though the disease has lasted some time ; for in 
two instances, which I can now distinctly recall, and in which 
the disease had existed for several years, the most careful 
microscopic examination failed to reveal the slightest change 
in their structure. 

You observe that both these patients are able to move 
their afi'ected extremities to a certain extent, although the 
amount of atrophy is considerable in each, and that there are 
certain muscles which are more implicated than others. In 
this little girl the tibialis anticns appears to be very weak, 



OKGANIC INFAl^TILE PAEALYSIS. 281 

and allows the toes to drop wlienever she raises lier foot from 
the ground ; and the same muscle is likewise involved, together 
with the peronei, in this little boy, to such a degree that the 
opposing group of muscles, although diseased, are still power- 
ful enough to distort the limb, and produce that kind of club- 
foot which we designate talipes equino-varus. You see also 
that the hand has a tendency to close, so that the fingers are 
drawn into the palm, but he can extend them through a 
strong efibrt of volition. 

The power of the will is diminished, but not abolished, 
even in those muscles that are the most affected ; but after a 
while, as the disease progresses, the influence of volition will be 
destroyed, and the distortions that exist will become permanent, 
if the treatment be not continued. The extensor muscles in 
this, as in some other forms of paralysis, generally lose their 
electric contractility to a greater degree than the others, and 
consequently we find that they resist treatment longer. You 
must, however, bear in mind that the mere fact of the electric 
contractility being lost to a Faradic current, howsoever strong 
it may be, is no certainty that the muscular tissue has under- 
gone degeneration, f^r we find that this current is unable to 
produce contractions in cases when a weak galvanic battery 
will readily cause them to take place ; consequently, in arriving 
at an accurate prognosis, it is necessary in the first place to 
examine carefully portions of the fibres of the afi'ected muscles 
to see to what extent their tissue is involved. If the trans- 
verse striae still exist, and fatty degeneration has not taken 
place to an extreme degree, and there still remain enough 
muscular fibres to contract to a strong galvanic current, the 
prognosis is favorable, and the only two elements that will be 
required to efiect a favorable result are perseverance and time. 

Another point of importance is, that there is no tendency 
in this disease for the paralysis to extend beyond the limits of 
the muscles first involved. But there is, on the contrary, a 
strong disposition toward the repair of the spinal lesion which 
results generally in a partial restoration of motility before the 
commencement of atrophy. 

In organic infantile paralysis the bladder is not involved, 
as it so often is in other forms of spinal disease ; neither is con- 



282 CLINICAL LECTURES. 

stipation nor diarrhoea a constant symptom, althongli either 
of these conditions may be occasionally present. 

The tendency in this affection to muscular atrophy, and 
the permanent character of the paralysis, sufSce to distin- 
guish it from those cases of anaemia of the anterior columns 
of the spinal cord which have been confounded with this dis 
ease. 

In the large number of cases of organic infantile paral- 
ysis which have come under my care within the last eight 
years, I have been unable in the majority of them to find an 
adequate cause for the onset of the disease. It may, however, 
supervene after any of the diseases of infancy, or after undue 
exposure to cold. In the two cases before us we find that one 
followed an attack of diarrhoea, and for the other we are im- 
able to assign any cause. 

The first sign of improvement in the muscles is an increase 
in the temperature of the aff'ected parts. For ascertaining 
this, I generally employ Becquerel's disks, which will deter- 
mine witli absolute certainty a variation of the one-hundredth 
of a degree. By means of this apparatus we can accurately 
note slight changes in the rise of tem|>erature which take 
place from time to time, and which indicate an improvement 
in the circulation and nutrition of the parts. 

I will now pass to the consideration of the treatment, 
which I generally divide into general and local. Of these, 
however, the latter is of the most importance. During the 
acute stage, I require that the patient should be confined to 
his bed, and kept absolutely quiet, no medication being of 
any benefit during this condition, so far as I know. After 
the acute symptoms have passed, and the disease has be- 
come chronic, our attention is to be particularly directed tow- 
ard the trouble of the muscles. As a tonic to the muscles 
and a general stimulant to the nervous system, I know of no 
remedy that will fulfill these conditions better than strychnia. 
It may be given in doses of a thirty-second of a grain three 
times a day, either alone or in conjunction with iron, quinine, 
and phosphorus. I generally, however, prefer an hypodermic 
injection of the thirty-second of a grain of strychnia every 
other day, which is to be increased or diminished, according 



OEGANIC II^FANTILE PARALYSIS. 283 

to tlie age of the patient. By local treatment we aim to pro- 
mote nutrition of the mnseles, and increase their contractile 
power. The first result is accomplished by increasing the 
amount of blood, and causing it to How more quickly through 
the diseased mnscles ; and, for this purpose, heat, friction, and 
kneading, are the methods to be employed, while, in order to 
increase the contractile power of the muscles, electricity, to- 
gether with active and passive motion, are the chief means of 
accomplishing that end. 

In applying heat the limb should be immersed in hot 
water varying in temperature from 110° to 130°, according 
to the susceptibility of the patient, and it should be allowed 
to remain there for at least twenty minutes or longer, as the 
case may require. Frictions are also useful adjuvants, but, in 
order to be of any utility, they should be employed many 
times a day, and with sufficient force to redden the skin. 
But, of all these means, I consider kneading of the muscles 
the most efficacious. In order to produce the desired effect, 
the diseased muscles should be strongly pinched to the extent 
of exciting pain, and in this manner the affected parts should 
be gone over thorou^jhly once or twice a day. After this pro- 
cess has been carefully performed, the redness of the surface 
will readily indicate the increase of the amount of blood in 
the parts. 

Our main reliance, however, depends upon electricity in 
some one of its forms. If contractions can be produced by 
the induced current, we should steadily employ it. But if 
this agent fails us as it so often does, especially when the dis- 
ease has only lasted a short time, we should have to make 
use, as a last resort, of the primary galvanic current. If we 
are unable to elicit from a powerful battery of this kind, after 
a few trials, any contractions, the case is hopeless ; and, if we 
examine microscopically fibres of the muscles in such in- 
stances, we shall find that the muscular striae have disap- 
peared. But, if even the feeblest contractions exist in response 
to a strong galvanic current, no matter howsoever slight they 
may be, we should persevere, and in time success will crown 
our efforts. In addition to electricity in those cases where 
the power of will has been more or less impaired, the joints 



284 CLINICAL LECTURES. 

slioTild he freely moved daily, and the child taught to hring 
the diseased muscles into activity through a strong effort of 
the will. Before closing this subject, I have one other case 
to bring before you, v^^hich is interesting from the fact that, 
although it resembles organic infantile paralysis in its effects, 
nevertheless, on careful examination of the history of the case, 
you will perceive that it differs from that affection in several 
important particulars. 

Case III. Paralysis with Distortion, jprobahly the Result 
of Spinal Meningitis. — " A boy, aged ten years, was brought 
to the clinic, suffering from paralysis of the forearm, and 
paralysis with distortion of the right leg. It appears that he 
was a healthy child until he reached his second year, when he 
had a violent attack of vomiting and purging, which was fol- 
lowed by convulsions, accompanied with opisthotonos, which 
occurred at intervals for several weeks. 

Such was the brief history of this case prior to his admis- 
sion to the clinic, at which time his condition was as follows ; 
He seemed to be in good general health, but there existed pa- 
ralysis of the right forearm and leg. The foot was distorted 
through a paralysis of the peronei and tibialis anticus muscles, 
while the heel was drawn up, producing a deformity which 
might be called talipes equino-varus. Often you would notice 
movements, similar to chorea, take place in the left shoulder, 
and these shrugging or jerking motions were at times very evi- 
dent. When he was excited, he was able to move the right 
arm quite freely, but, as soon as the excitement abated, he was 
unable to give it much motion. When he moved the forearm, 
he always moved the whole arm at the same time, and then 
he was able to perform movements very satisfactorily. In all 
the movements of the diseased members there was the associ- 
tion of coordinated movements in other parts of the body ; 
when he wished to raise the whole arm, there was associated 
therewith a movement of the shoulder. If he moved the leg, 
he was obliged to throw his body backward. In fact, all his 
movements on the diseased side were associated with move- 
ments in some other part of the body. He was unable to 
raise his toes through an effort of the will, although he could 
elevate his knee." 



ORGATsHC INFANTILE PAEALYSIS. 285 

This boy appears to be suffering from infantile paralysis, 
but such, I think, is not the case. You observe that there is 
an extreme degree of paralysis in the peronei and tibialis an- 
ticus muscles, and as a consequence the foot is drawn inward, 
while the gastrocnemius and soleus contract tonically and 
shorten the muscles at the back of the leg to such an extent 
as to elevate the heel to a considerable degree. You see, 
however, that it requires some force to overcome the resistance 
and bring the heel into its proper position. It is through the 
paralysis and contractions of the different healthy muscles of 
the legs that the various forms of club-foot are produced, for 
in this way their natural antagonism is destroyed, and de- 
formities are the result. Some of these instances take place 
before the birth of the child, and they are therefore born with 
distortions of the extremities. 

You remember that the trouble commenced with this boy 
Tvhen two years old, with vomiting and purging, and this was 
succeeded by spasms accompanied with opisthotonos, occurring 
at intervals during several weeks. In all probability he had 
either an attack of congestion of the cord or inflammation of 
the meninges, and I should be rather inclined to think the lat- 
ter of those affections, for violent contractions are one of the 
main symptoms indicative of the disease of the meninges of the 
cord. It is not usual to have spasms in congestion of the cord 
itself unless the meninges are involved. I have seen cases in 
which the spasms affected both sides of the body, and yet 
there remained, as a result, paralysis upon one side only. 

Such appears to have been the sequence in this case. This 
is not exactly such an example as I have already brought be- 
fore you to illustrate organic infantile paralysis. It rather re- 
sembles the remains of a spinal meningitis which has been fol- 
lowed by paralysis of the right forearm, and paralysis with 
distortion of the right leg. You observe that now, while he 
is excited, he moves his right arm very readily, whereas while 
he was quiet he was unable to do so. This shows conclusively 
that he has at times a certain amount of voluntary power 
over the right arm. Besides, if you watch him closely, you 
will see, every now and then, a shrugging or jerking of the 
left shoulder which very closely resembles chorea. His move- 



286 CLLNTICAL LECTURES. 

ments are, as jou see, not such as a child would make if full 
Toluntarj power were present. He cannot move the forearm 
without moving the whole arm, and sometimes he can per- 
form these movements better than at others. 

In this case the influence of coordinated movements is 
well illustrated. Some people, jou know, who stammer, can 
speak freely if they do something else at the same time ; and, 
not unfrequently, persons can be broken of stammering by 
directing them to associate some other movements of the body 
with their efforts of speaking. Sometimes nothing more is 
required than merely tapping the thigh lightly with the fin- 
ger, or some equally simple motion. The result is, that the 
associated movement corrects the stammering, and the person 
speaks without hesitation. A like circumstance takes place in 
this boy's arm. He cannot make a simple motion of the fore- 
arm without throwing back the arm. When he wishes to 
raise the whole arm from his side, he brings into play the 
shoulder or some other part of the body simultaneously. From 
this fact you see that there is no actual paralysis of the deltoid, 
because, when the movement of the shoulder is associated, the 
arm is raised. 

But the main point of inquiry in this case is. What will 
benefit the boy? In the first place, I should advise the di- 
vision of the tendo-Achilies, and then to draw down the foot, 
and retain it in its natural position by some simple ap- 
paratus. Then I should proceed to act systematically upon 
the muscles with the electric current, and, if these muscles 
possess any contractility, I should expect, with time and 
perseverance, to improve his condition materially. When I 
come to compare the length of the right leg with that of the 
left, I find an appreciable amount of shortening, which be- 
tokens an arrest of development often occurring in these cases. 
To overcome this deficiency, he will be- obliged to wear some 
apparatus to make up for the shortening, for he will not, in all 
probability, regain the loss of length, which he might do if 
younger. In one case of infantile paralysis of the arm which 
I had under my observation, and which was shortened fully 
three-quarters of an inch, the arm grew out equal to the other 
under the influence of the primary galvanic current. One 



OEGAISIC mFANTILE PAEALYSIS. 287 

electrode was placed upon the head of the radius, and the 
other applied to the various muscles. In the course of time 
the limb increased in length and size, and, when the child 
passed from under my care, he was fully cured. In addition 
to galvanism, I should make use of an hypodermic injection of 
strychnia, from the one-fortieth to the one-thirtieth of a grain, 
according to circumstances, every other day, and increase it, 
if I thought it necessary. 



THE END. 



I If D E X 



PAGE 

Aborted epilepsy 143 

case of 143 

symptoms 144 

treatment 145 

Active cerebral congestion. ...... 182 

case of 182 

symptoms 184 

apoplectic form of , . . . . 192 

symptoms 196 

epileptic form of 198 

diagnosis 201 

prognosis ' 201 

symptoms 202 

Alternate or cross-hemiplegia. ... 14 

Anaemia, partial cerebral 1 

Anatomy of the facial nerve. ... 19, 81 

Aphasia, history 64 

pathology 5Y 

amnesic 59 

ataxic 59 

agraphia 60 

cases of 61, 62, 64, 74 

causes 12 

symptoms.. 72 

prognosis 77 

treatment 77 

Athetosis 145 

case of 145 

symptoms 145 

pathology 146 

morbid anatomy 146 

treatment 146 

Atrophy, progressive muscular. . . 147 

vBouillaud, views of 65 

experiments of 57 

Broca, views of 66 

Cerebral congestion 180 

causes 204 

treatment 206 

Cerebral embolism 9 

pathology 9 

case of 10 

symptoms 12 

prognosis 12 

diagnosis 13 

treatment 13 

19 



PAGE 

Cerebral hemorrhage 104 

cases of 105, 110, 118 

symptoms 107, 113, 121 

diagnosis 112 

causes 113, 122 

prognosis 122 

pathology 123 

treatment 109, 116, 124 

Cerebral thrombosis 1 

case of 1 

symptoms 4 

causes 7 

prognosis 7 

treatment 7 

Cerebral thrombosis with cross- 
paralysis 130 

case of 130 

symptoms 133 

diagnosis 134 

pathology 134 

Cervico-occipital neuralgia 254 

case of 254 

symptoms 256, 260 

causes 259 

diagnosis. 260 

prognosis 259 

treatment , 259 

Chronic basilar meningitis 171 

cases of 171,174,175 

symptoms 172, 176 

causes 178 

diagnosis 171 

prognosis. . ... 173, 178, 179 

pathology 172, 176 

treatment 178 

Chronic myelitis 22 

cases of 23, 25 

symptoms 29 

diagnosis 29, 35 

prognosis 35 

treatment 35 

Chronic spinal meningitis 33 

case of 33 

symptoms 33 

diagnosis 29, 35 

prognosis 35 

treatment 35 

Chorea, case of 49 



290 



IKDEX. 



Chorea, symptoms, 
causes 



PAGE 

50 

51 

prognosis 52 

pathology 50 

treatment 53 

Congestion, cerebral 180 

Congestion, spinal 22 

Convulsive tremor 164 

cases of 164, 166, 167, 169 

history 165 

diagnosis 165 

pathology 168, 169 

treatment 170 

Cross-paralysis 14 

case of 15 

symptoms 19 

pathology 19 

treatment 21 

Dax, views of 55 

Duchesne, views of 100 

Dura mater, haematoma of 125 

Embolism, cerebral 9 

Epilepsv, aborted 143 

Epilepsy 209 

paroxysm, varieties of 209 

cases.' 210, 240 

symptoms 214, 232 

causes 242 

diagnosis 234, 242 

prognosis 225, 243 

treatment 217, 225, 232 

Epileptiform cerebral congestion, . 198 
Experiments of Bouillaud. ....... 57 

Facial nerve, anatomy of 19, 81 

Facial neuralgia 244 

Facial paralysis 78 

case of 79 

symptoms 79 

causes 83 

pathology 84 

diagnosis 85 

prognosis 85 

treatment 86 

Gall, views of 54 

Glosso-labio-laryngeal paralysis. . . 88 

ease of 89 

symptoms 95 

pathology 95, 102 

morbid anatomy 100, 101 

causes 102 

prognosis 103 

treatment 113 

Hsematoma of the dura mater. . . . 125 

pathology 125 

case of 126 

symptoms 127 



PAGE 

Haematoma of the dura mater, di- 
agnosis 129 

causes 129 

prognosis 129 

treatment 129 

Haemorrhage, cerebral 164 

Intercostal neuralgia 261 

case of 261 

treatment 262 

Jackson, views of 55 

Lead-paralysis, case of 39 

pathology .... 43 

symptoms 45 

prognosis 47 

treatment 48 

Meningitis, basilar chronic 171 

Meningitis, spinal chronic 33 

Moxon, views of 58 

Myelitis, chronic 22 

Xerve, facial, anatomy of 19, 81 

Xeuralgia 244 

cervico-occipital ^4 

occipito-cervico-brachial 256 

intercostal 261 

sciatic 263 

Xeuralgia of the fifth pair of nerves. 244 

cases of 244, 246, 249 

treatment. . • 252 

Occipito-cervico-brachial neuralgia. 256 

case of 256 

causes 259 

prognosis 259 

diagnosis 260 

symptoms 260 

treatment 259, 261 

Organic infantile paralysis 273 

cases 274, 276 

pathology 274 

symptoms 278 

morbid anatomy 280 

prognosis 281 

diagnosis 282 

causes 282 

treatment 282 

Paralysis, spinal 22 

reflex 22 

lead 39 

facial 78 

glosso-labio-laryngeal 88 

organic infantile 273 

Paralysis with distortion 284 

case of 284 

symptoms . 285, 286 

diagnosis 285 



INDEX. 



291 



PAGE 

Paralysis with distortion, treat- 
ment 286 

Partial cerebral ancemia 1 

Passive cerebral congestion 187 

case of 187 

symptoms 190 

Posterior spinal sclerosis 135 

cases of 135, 141 

symptoms 136, 143 

diagnosis 137 

causes 139 

prognosis 140 

treatment 139, 143 

Posterior spinal sclerosis and pro- 
gressive muscular atrophy 156 

case of 156 

symptoms 162 

pathology 162 

treatment 163 

Progressive muscular atrophy. . . . 147 

case of 147 

symptoms 151 

causes 155 

diagnosis. 156 

prognosis 156 

pathology 156 

morbid anatomy 156 

treatment 163 

Reflex paralysis 22 

case of 34 

causes 34 

symptoms 35 

diagnosis 35 i 



PAGE 

Reflex paralysis, prognosis 35 

treatment 39 

Sciatica 263 

cases of 263, 266 

symptoms 268 

causes 269 

diagnosis 269 

prognosis 269 

treatment 269 

Sclerosis, posterior spinal 135 

Spinal congestion 22 

case of. 22 

symptoms 29 

diagnosis ... 29, 35 

prognosis 35 

treatment 35 

Spinal paralysis 22 

Stupor 181 

Thrombosis, cerebral 1 

Thrombosis, cerebral, with cross- 
paralysis 130 

Tremor, convulsive 164 

Trousseau, views of 100 

Views of Bouillaud 55 

Broca 55 

Dax, , . 55 

Duchesne 100 

Gall 54 

Hughlings Jackson 55 

Moxon 58 

Trousseau 100 



DESCRIPTIVE CATALOGUE 



OF 



Medical Woeks 




D. APPLETON & CO., 



PUBLISHERS AND IMPORTERS, 



649 & 551 BROADWAY, NEW YORK. 



1874. 



IXDEX OF SUBJECTS. 



PAGE 

Anatomy , 15 

Anaesthesia 25 

Acne 81 

Body and Mind. IT 

Cerebral ConTolutions T 

Chemical Examination of the Urine in Dis- 
ease 8 

Chemical Analysis 13 

*" Technology 30 

Chemistry of Common Life 16 

Clinical Electro-Therapentica 10 

" Lectures 31 

Comparative Anatomy 6 

Club-foot 24 

Diseases of the Xervous System 11 

u a ii Xerves and Spimd Cord .... 31 

- » " " Bones 18 

" '• Women 25, 2€ 

" '• the Chest 25 

"Children 28,31 

" "theEectnm 2S 

" " the Oraries 30 



Electricity and Practical Medidne. 
Foods 

Galvano-Therapeutics 



Hospitalism 

Histology and Histo-Chemistry of Man. . . . 

Infancy 

Tn sanity in its Eelation to Crime 



Materia Medica and Therapeutics . 
Medical Journal 



PAGE 

Mental Physiology 5 

Midwifery'. 25,26 

Mineral Springs 29 

2s euralgia 8 

Xervous System 12 

Xursing 22 

Ovarian Tumors 28 

" Diagnosis and Treatment 30 

Obstetrics 4, S, 25 

Physiology 9. 10 

Physiology of Common Life 16 

Physiology and Pathology of the Mind 17 

Physiological Effects of Severe Muscular 

Exercise 11 

Pulmonary Consumption. 5 

Practical Medicine 20 

Physic^ Cause of the Death of Christ 24 

Popular Science 82 

Puerperal Diseases 2 

Eei)orts ., 4 

Eecollections of Past Life 14 

" of the Army of the Potomac.. 16 

EesponsibUity in Mental Diseases 15 

Sea-sickness 2 

Surgical Pathology 5 

" Diseases of the Male Genito-Uri- 

nary Organs 27 

Surgery 7 

Syphilis 27 

Science 30, 32 

Skin Diseases 21 

Uterine Therapeutics 2 

Winter and Spring 4 



CATALOGUE 

OF 

MEDICAL WORKS. 



ANSTIE. 

JN CUr3-lgl3<, and Diseases which resemble it. 

By FRANCIS E. ANSTIE, M. D., F. R. C. P., 

Senior Assistant Physician to "Westminster Hospital ; Lecturer on Materia Mediea in Westminster 
Hospital School; and Physician to the Belgrave Hospital for Children; Editor of "The 
Practitioner" (London), etc. 

1 vol., 12nio. Clotli, $2.50. 

" It is a valuable contribution to scientific medicine." — The Lancet {London). 

BARKER 
The Puerperal Diseases, cmiicai Lectures 

delivered at Bellevue Hospital. 

By FORDYCE BARKER, M. D., 

Chnical Professor of Midwifery and the Diseases of "Women in the Bellevue Hospital Medical 
College ; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York 
State "Woman's Hospital; Fellow of the New York Academy of Medicine; formerly Presi- 
dent of the Medical Society of the State of New York ; Honorary Fellow of the Obstetrical 
Societies of London and Edinburgh; Honorary Fellow of the Eoyal Medical Society of 
Athens, Greece, etc., etc., etc. 

1 vol., 8vo. Clotli. 526 pages. Price, $5.00. 

" For nearly twenty years it has been my duty, as well as my privilege, to give clinical lect- 
ures at Bellevue Hospital, on midwifery, the puerperal and the other diseases of women. This 
volume is made up substantially from phonographic reports of the lectures which I have given 
on the puerperal diseases. Having ^^d rather exceptional opportunities for the study of these 
diseases, I have felt it to be an imperative duty to utilize, so far as lay in my power, the advan- 
tages which I have enjoyed for the promotion of science, and, I hope, for the interests of human- 
ity. In many subjects, such as albuminuria, convulsions, thrombosis, and embolism, septicaemia, 
and pyaemia, the advance of science has been so rapid as to make it necessary to teach something 
new every year. Those, therefore, who have formerly listened to my lectures on these subjects, 
and who now do me the honor to read this volume, will not be surprised to find, in many par- 
ticulars, changes in pathological views, and often in therapeutical teaching, from doctrines before 
inculcated. At the present day, for the first time in the history of the world, the obstetric de- 
partment seems to be assuming its proper position, as the highest branch of medicine, if its rank 
be graded by its importance to society, or by the intellectual culture and ability required, as 
compared with that demanded of the physician or the surgeon. A man may become eminent as 
a physician, and yet know very httle of obstetrics ; or he may be a successful and distinguished 
surgeon, and be quite ignorant of even the rudiments of obstetrics. But no one can be a really 
able obstetrician unless he be both physician and surgeon. And, as the greater includes the less, 
obstetrics should rank as the highest department of our profession."— ..^rom Author's Preface. 



On Sea-sickness. 



By FORDYCE BARKER, M. D. 
1 vol., 16mo. 36 pp. Flexible Clotli, 76 cents. 

Eeprinted from the New Yoek Medical Jottknal. By reason of the great demand for the 
number of that journal containing the paper, it is now presented in book form, Avith such pre- 
scriptions added as the author has found useful in reUeving the suffering from sea-sickness. 



4 D. Appleton c& Co.'s Medical Publications. 

BAKISTES. 

Obstetric Operations, including the Treatment 
of Hcemorrhage. 

By ROBERT BARXES, M. D., F. R. C. P., London, 

Obstetric Physician to and Lecturer on iIid^vife^y and the Diseases of Women and Children at 
St. Thomas's Hospital; Examiner on Midwifery to the Eoyal College of Physicians and to 
the Eoyal College of Surgeons ; formerly Obstetric Physician to the London Hospital and 
late Physician to the Eastern Division of the Eoyal Maternity Charity. 

WITH ADDITIONS, by BEXJAMIX F. DAWSON, M. D., 

Late Lecttirer on Uterine Pathology in the Medical Department of the University of Xew 
York ; Assistant to the Clinical I*rofessor of Diseases of Children in the College of Physicians 
and Surgeons. Xew York : Physician for the Diseases of Children to the ^Tew York Dis- 
pensary; Member of the iNew York Obstetrical Society, of the Medical Society of the 
County of Xew York, etc.. etc. 

Second American Edition. 1 voL, 8vo. 503 pp. Cloth, $4.50. 

" Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate the practice 
of the obstetric art in this cotmtry, and to be of great service to the practitioner." — Lancet. 

Bellevue and Charity Hospital Reports. 

The volume of Bellevue and Charity Sospital Reports 
for 1870, containing valuable contributions from 

ISAAC E. TAYLOE. M. D., AUSTIN FLINT, M. D., LEWIS A. SAYEE, M. D., TH^L- 
LIAM A. HAMMOND, M. D., T. GAILLAED THOMAS, M. D., FRANK H. HAMIL- 
TON, M. D^ and others. 

1 vol., 8vo. Clotli, $4.00. 

"These institutions are the most important as regards accommodations for patients and 
variety of cases treated, of any on this continent, and are surpassed by but few in the world. 
The gentlemen connected with them are acknowledged to be among the first in their profession, 
and the volume is an lmj>ortant addition to the professional literature of this coimtry." — Psycho- 
logical Journal. 

BEisrisrET. 
Winter and Spring on the Shores of 

the J\Iediterraneaji ; or, the Riviera, Mentone, Italy, 
Corsica, Sicily, Algei'ia, Spain, and Biarritz, as Win- 
ter Climates. 

Bt J. HENRY BENNET, M. D., 

Member of the Royal College of Physicians. London ; late Physician-Acconcheur to the Royal 
Free Hospital :' Doctor of Medicine of the University of Paris ; formerly Resident Physician 
to the Paris Hospital (ex-Interne des H(5pitaux de Paris), etc. 

This work embodies the experience of ten winters and springs passed by Dr. Bennet on the 
shores of the Mediterranean, and contains much valuable information for physicians in relation 
to the health-restoring climate of the regions described. 

1 vol. 12mo. 621 k>. Cloth, $3.60. 

"Exceedingly readable, apart from its special purposes, and well illustrated."— ^r^niTi^ 
Commercial. 

'• It has a more substantial value for the physician, perhaps, than for any other class or pro- 
fession. . . . We commend this book to "our readers as a volume presenting two capital 
qualifications — it is at once entertaining and instructive."" — X. Y. Medical Journ<il. 



D. Appleton cb Co.^s Medical Puhlicatio7is. 5 

BENNET. 
On the Treatment of Pulmonary Con- 

sumptio7i, by Hygiene^ Climate^ and Medicine, in its 
Connection with Modern Doctrines, 

By JAMES HENRY BENNET, M. D., 

Member of the Eoyal College of Physicians, London ; Doctor of Medicine of the University ol 

Paris, etc, etc. 

1 vol., thin 8vo. Cloth, $1.50. 

An interesting and instructive work, written in the strong, clear, and lucid manner which 
appears in all the contributions of Dr. Bennet to medical or general literature. 

" We cordially commend this book to the attention of all, for its practical common-sense views 
of the nature and treatment of the scourge of all temperate chmates, pulmonary consumption." 
— Detroit Review of Medicine. 

BILLROTH. 
General Surgical Pathology and Th.^- 

rap)eutics^ in Fifty Lectures, A Text-book for Students 

and Physicians. 

By Dr. THEODOR BILLROTH. 

Translated frora th.e Fifth Grermaii Edition, with the special permission 

of the Author, by 

CHARLES E. HACKLEY, A. M., M. D., 

Surgeon to the New York Eye and Ear Infirmary; Physician to the New York Hospital; 
Fellow of the New York Academy of Medicine, etc. 

1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, S6.00. 

Professor Theodor Billroth, one of the most noted authorities on Surgical Pathology, gives in 
this volume a complete remrne of the existing state of knowledge m this branch of medical 
science. The fact of this pubUcation going through four editions in Germany, and having been 
translated into French, Itahan, Eussian, and Hungarian, should be some guarantee for its standing. 

" The want of a book in the English language, presenting in a concise form the views of the 
German pathologists, has long been felt ; and we venture to say no book could more perfectly 
supply that want than the present volume. . . . We would strongly recommend it to all who 
take any interest in the progress of thought and observation in siu-gical pathology, and surgery." 
—The Lancet. 

'■'• We can assure our readers that they will consider neither money wasted in its purchase, 
nor time in its perusal." — The Medical Investigator. 

CARPENTER 

Principles of Mental Physiology^ with 

their Applications to the Training and Discipline of the 
Mind and the Study of its Morbid Conditions, 

By WM. B. carpenter, M. D., LL. D., F. R. S., F. L. S., F. G. S., 

Registrar of the University of London ; Corresponding Member of the Institute of France and 
of the American Philosophical Society, etc., etc. 

" Among the numerous eminent writers this country has produced, none are more deserving 
of praise for having attempted to apply the results of Physiological Eesearch to the explanation 
of the mutual relations of the mind and body than Dr. Carpenter. To him belongs the merit of 
having scientifically studied and of having in many instances supplied a rational explanation of 
those phenomena which, under the names of mesmerism, spirit-rapping, electro-biologj^ and 
hypnotism, have attracted so large an amount of attention during the last twenty years. . . . We 
must conclude by recommending Dr. Carpenter's work to the members of our own profession as 
appljang many facts, that have hitherto stood isolated, to the explanation of the functions of the 
brain and to psychological processes generally." — The Lancet. 



6 D. AppUton & Co.^s Medical Publications. 

COMBE. 

The Management of Infancy, Physiologi- 
cal and Moral. Intended chiefly for the Use of 
Parents. 

By ANDREW COMBE, M. D. 

REVISED AND EDITED 

By Sie JAMES CLARK, K. C. B., M. D., F. R. S., 

Physician-iD-ordiiiary to the Queen. 

First American from the Tenth London Edition. 1 vol., 12mo. 302 pp. 

Cloth, S1.50. 

"This excellent little book should, be in the hand of every mother of a family; and, if some 
of our lady Mends would master its contents, and either bring- up their children by the light of 
its teachings, or communicate the truths it contains to the poor by Trhom they are surrounded, 
we are conrinced that they would effect infinitely more good than by the distribution of any 
number of tracts whatever.' . . . "We consider this work to be one of "the few popular medical 
treatises that any practitioner may recommend to his. patients ; and. though, if its precepts are 
followed; he will" probably lose a few gtuneas. he will not begrudge them if he sees his friend's 
children' grow up healthy, active, strong, and both mentally and physically capabk." — The 
Lancet. 

CHAUVEAU. 

The Comparative Anatomy of the 

Domesticated Animals. 

By a. CHArTEAU, 

PEOFESSOE AT THE LTOyS VETEELN-AET SCHOOL. 

Second edition, revised and enlarged, with the cooperation of S. ARLOIXG, 
late Principal of Anatomv at the Lyons Veterinary School ; Professor at the 
Toulouse Yetermary School. Translated and edited by GEORGE FLEMING, 
F, R. G. S., M. A. L, Veterinary Surgeon, Royal Engineers. 

1 vol., 8vo. Cloth. 957 pp., with 450 Illustrations. Price, $6.00. 



OPINIONS OF THE PRESS. 

" This is a valuable work, well conceived and well executed by the authors, MM. Chauveau 
and Arloing. and well translated by Mr. Fleming. It is rather surprising how few works exist, 
in any language, in which the anatomy of the commoner animals, domestic and otherwise, is 
given'^s^ithany approach to detail. Systematic works there are in abtmdance. but. if the student 
be desirous of ascertaining any particular point, such as the position and branches of the 
pneumogastric or sj-mpathetic nerves, or the homologue of a given muscle in several different 
animals.^he may search aU day ere he find it. The work before us appears to be well adapted to 
meet this difficulty. 

'• The Illustrations are very numerous, and Mr. Eleming has introduced a large number that 
r»re not contained in the original work. 

'• Taking it altogether, the book is a very welcome addition to Enghsh hterature. and great 
credit is due to Mr. Pleming for the excellence of the translation, and the many additional notes he 
has appended to Chauveau^s treatise." — Lancet {Londoii). 

"The want of a text-book on the Comparative Anatomy of the Domesticated Animals has 
long been felt. . . . The descriptions of the text are Ulustrated and assisted by no less than 450 
excellent woodcuts. In a work which ranges over so vast a field of anatomical detail and de- 
scription, it is difficult to select any one portion for review, but our examination of it enables us 
to speak in high terms of its general excellence. . . . The care and attention Avith which hippot- 
omy has been cultivated on the Continent are illustrated by every page in M. Chauveau's work. 
—Medical Tinier and Gazette {London). 



D, Appleton <& Co.^s Medical Publications. '7 

DAYIS. 

Conservative Surgery, as exUUtedin remedying 
some of the Mechanical Causes that ojperate injuri- 
ously both in Health and Disease. With Illustrations. 

By HEI^EY G. DAYIS, M. D., 

Member of the American Medical Association, etc., etc 

1 vol., 8vo. 315 pp. Cloth, $3.00. 

The author has enjoyed rare facilities for the study and treatment 
of certain classes of disease, and the records here presented to the pro- 
fession are the gradual accumulation of over thirty years' investigation. 

" Dr. Davis, bringing, as he does to his specialty, a great aptitude for the 
solution of mechanical problems, takes a high rank as an orthopedic surgeon, 
and his very practical contribution to the literature of the subject is both valu- 
able and opportune. We deem it worthy of a place in every physician's hbrary. 
The style is unpretending, but trenchant, graphic, and, best of all, quite intelli- 
gible." — Medical Record. 

ECKER 
The Cerebral Convolutions of Man, 

rejpresented according to Personal Investigations, es- 
jpecially on their Development in the Foetus, and with 
reference to the Use of Physicians. 

By ALEXAITDER ECKER, 

Professor of Anatomy and Comparative Anatomy in the University of Preiburg. 

Translated from the German by Robert T. Edes, M. D. 

1 vol., 8vo. 87 pp. $1.25. 

" The work of Prof. Ecker is noticeable principally for its succinctness and 
clearness, avoiding long discussions on undecided points, and yet sufficiently 
famished with references to make easy its comparison with the labors of oth- 
ers in the same direction. 

" Entire originality in descriptive anatomy is out of the question, but the 
facts verified by our author are here presented in a more intelligible manner 
than in any other easily-accessible work. 

" The knowledge to be derived from this work is not furnished by any other 
text-book in the English language." — Boston Medical and Surgical Journal^ 
January 20, 18Y3. 



8 D. AppUton <£• Coh Jledical Puhlkations. 

ELLIOT. 

Obstetric Clinic, a Practiced Contribution to the 
Study of Olstetrics, and the JJlseasts of Women and 
Children. 

Bv the late GEORGE T. ELLIOT, M. D., 

Late Professor of Obstetrics and the Diseases of Women, and CMldren in the Bellevue Hospital 
MediiSil CoHege : Physician to Belle vne Hospital and to the ^S ew York Lyin^-in Asylxun ; 
Consniring Physidan to the >inrierr and Child's Hospiral: Consnirln^ Snrgecn to the State 
Woman's Hospiial: Correspon-iin^'Meml^r of_the E^iinhurgh Obstetrical SKietvand of the 
Eoval Academy oi Havana : fellow of the > . Y. Academy of Medicine ; Member <rf die 
Coimty Medical Society, oi the Pathjlogic-al S-x-iety. etc. etc' 

1 vol,, 8vo. 458 pp. Cloth, S4.50. 

This "vrork is. in a measure, a resume of separate papers preTiously 
prepared by the late Dr. Elliot : and contains, besides, a record of nearlv 
two hundred important and difficult cases in midwifery, selected from 
his own practice. It has met with a hearty reception, and has received 
the highest encomiums both in this country and in Etirope. 

" The volume by Dr, "FTH ot has scarcely less value, though in a diSFerent direction, than that 
of the Edinbnrgh physician (Dr. Duncan. •Eesearches in Obstetrics ')." — Lin^^-it 

- There is no CKX)k in American obstetrical literature that surpasses this (sii."—3iinburgh 
Medical Journal. 

'" It ought to be in the hands of every practitioner of midwifery in the country.-' — Bo^on 
Medical and Surgical Journal. 

" It has no equal in the "English language, as regards diiueal instraction in obst^HCS." — 
Ainericart, Jourrtol of Oo^^eiricA. 

FLINT. 
Manual of Chemical Examination of 

the Urine in Disease. With Brief Directions for the 

Examination of the most Common Yarletie-s of Urinary 

Calculi. 

By AUSTIX FLIST, Jb., K D., 

Professor of Physiology and Microscopy in the Belle vue Hospital Medical College : Fellow of the 
5^ew York Academy of Medicine"; Member of the Meiiicai Society of the County of Xew 
Yort ; Eesident Member of the Lyceum of 2s^acural History ia the City of ^ew York, etc. 

Third Zditioii, revised and corrected. 1 vol., 12mo. 77 pp, Clotli, $1.00. 

The chief aim of this little work is to enable the busy practitioner to 
make for himself, rapidly and easily, all ordinary examinations of Urine; 
to give him the benefit of the author's experience in eliminating little 
difficulties in the manipulations, and in reducing processes of analysis 
to the utmost simplicity that is consistent with accuracy. 

" We do not know of any work ia English so c<Hni>Iete and handy as the "SfanTial now offered 
to tiie profession by Dr. Fhnt. and the high scientifie repotation of the author is a snSSdent 
guarantee of the aceoracy of all the directions given,*' — Journal of ApplUd Chemistry, 

*" We can nnhesitatinglT recommend this Manual^ — Psychologioal Journai. 

" Eminently practicaL"— 2>efro!/ Retiexr of Medicint, 



2>. Appleton <& Co.^s Medical Fuhlications, 9 

FLINT. 

The Physiology of Man. Designed to rej^- 
resent the Existing State of Physiological Science as 
applied to the Functions of the Human Body, 
By AUSTrN" FLINT, Je., M. D., 

Professor of Physiology and Microscopy in the Bellevue Hospital Medical Collega, and in the 
Long Island College Hospital; Fellow of the New York Academy of Medicine ; Microscopist 
to Bellevue Hospital 

In Five Volumes. 8vo. Tinted Paper. 
Yolume I. — The Blood ; Circulation; Respiration, 

8vo. 502 pp. Cloth, S4.50. 

** If the remaining portions of this work are compiled with the same care and 
accuracy, the whole may vie with any of those that have of late years been pro- 
duced in our own or in foreign languages." — British and Foreign Medico- Chirurgi- 
col Review. 

" As a book of general information it will be found useful to the practitioner, 
and, as a book of reference, invaluable in the hands of the anatomist and physi- 
ologist." — Duhliii Quarterly Journai of Medical Science. 

" The complete work will prove a valuable addition to our systematic treatises 
on human physiology." — The Lancet. 

" To those who desire to get in one volume a concise and clear, and at the 
same time sufficiently full resume of ' the existing state of physiological science,' 
we can heartily recommend Dr. Flint's work. Moreover, as a work of typographi- 
cal art it deserves a prominent place upon our library-shelves. Messrs. Appleton 
& Co. deserve the thanks of the profession for the very handsome style in which 
they issue medical works. They give us hope of a time when it will be very 
generally believed by publishers that physicians' eyes are worth saving. " — Medi- 
cal Gazette. 

Yolume II. — Alimentation / Digestion / Absorption / 
Lymph and Chyle. 

8vo. 556 pp. Cloth, $4.50. 

" The second instalment of this work fulfils all the expectations raised by the 
perusal of the first. . . . The author's explanations and deductions bear 
evidence of much careful reflection and study. . . . The entire work is one 
of rare interest. The author's style is as clear and concise as his method is 
studious, careful, and elaborate." — Fhiladelphia Inquirer. 

" We regard the two treatises already issued as the very best on human physi- 
ology which the English or any other language affords, and we recommend them 
with thorough confidence to students, practitioners, and laymen, as models of 
literary and scientific ability."— jV. Y. Medical Journal. 

" We have found the style easy, lucid, and at the same time terse. The prac- 
tical and positive results of physiological investigation are succinctly stated, 
without, it would seem, extended discussion of disputed points."— -5ostow Medical 
and Surgical Journal. 

" It is a volume which will be welcome to the advanced student, and as a 
work of reference." — The Lancet. 

" The leading subjects treated of are presented in distinct parts, each of which 
is designed to be an exhaustive essay on that to which it refers."— IFes^em Jour- 
nal of Medicine. 



10 D. Apphton c& Co?s Jledical Piihlicatioiis. 

Flint's Physiolog}^ Volume Ul.— secretion ; Ex- 
cretion; Ductless Glands; Kvirition ; Animal Heat ; 
JSIovenients ; Yoice and Speech, 

8vo. 526 pp. Clotli, $4,50. 

" Dr. Flint's reputation is sufficient to give a character to the book among the 
profession, where ii will chiefly circulate, and many of the facts given have been 
verified by the author in his laboratory and in public demonstration." — Chicago 
Courier. 

" The author bestows judicious care and labor. Facts are selected with dis- 
crimination, theories critically examined, and conclusions enunciated with com- 
mendable clearness and precision.'" — American Joarna! of the Medical Sciences. 

Yolume lY. — 'The iS'evcous System. 

8vo. Clotli, $4.50. 

This volume embodies the results of exhaustive study, and of a long and 
laborious series of experiments, presented in a manner remarkable for its strength 
and clearness. No other department of physiology has so profoimd an interest 
for the modem and progressive physician as that penaining to the nervous 
system. The diseases of this system are now engaging the study and attention 
of some of the greatest minds in the medical world, and iu order to follow their 
brilhant discoveries and developments, especially in connection with the science 
of electrology, it is absolutely necessary to obtain a clear and settled knowledge 
of the anatomy and physiology of the nervous system. It is the design of this 
work to impart that knowledge free from the perplexing speculations and uncer- 
tainties that have no real value for the practical student of medicine. The 
author boldly tests every theory for himself, and asks his readers to accept noth- 
ing that is not capable of demonstration. The properties of the cerebro-spinal, 
nervous, and sympathetic systems are treated of in a manner at once lucid, 
thorough, and interesting. 

Although this volume is one, perhaps the most important one, of the author's 
admirable series in the Physiology, of Man, it is nevertheless complete in itself, 
and may be safely pronounced indispensable to every physician who takes a pride 
and interest in the progress of medical science, 

Yolume Y. — S;pecioZ Senses ; Generation. 

8vo. Clotli, $4.50. 

" The present voltmie completes the task, begim eleven years ago, of preparing 
a work, intended to represent the existing state of physiological science, as ap- 
plied to the functions of the human body. The kindly reception which the first 
four volumes have received has done much to sustain the author in an under- 
taking, the magnitude of which he has appreciated more and more as the work 
has progressed. 

"In the fifth and last volume, an attempt has been made to give a clear account 
of the physiology of the special senses and generation, a most difficult and delicate 
undertaking. . , , 

"Finally, as regards the last, as well as the former volumes, the author can 
only say that he has spared neither time nor labor in their preparation ; and the 
imperfections in their execution have been due to deficiency in ability and oppor- 
tvmity. He indulges the hope, however, that he has written 'a book which may 
assist his fellow-workers, and interest, not only the student and practitioner of 
medicine, but some others who desire to keep pace with the progress of Natural 
Science," — EitracU from Preface. 



D. Appleton S Co.^s Medical Puhlications, 11 

FLINT. 
On the Physiological Effects of Severe 

and Protracted Muscular Exercise, With Sjpecial ref- 
erence to its Influence upon the Execretion of Nitrogen, 

By AUSTIN" FLINT, Je., M. D., 

Professor of Physiology in the Bellevue Hospital Medical College, New Tork, etc^ etc 

1 vol., 8vo. 91 pp. Cloth, $2.00. 

This monograph on the relations of Urea to Exercise is the result of a thorough and careful 
inyestigation made in the case of Mr. Edward Payson "Weston, the celebrated pedestrian. 
The chemical analyses were made under the direction of E. O. Doremus, M. D., Professor of 
Chemistry and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his 
assistant. The observations were made with the cooperation of J. C. Dalton, M. D,, Professor 
of Physiology in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Profess- 
or of Surgical Anatomy; W. H. Yan Buren, M. D., Professor of Principles of Surgery; Austin 
Flint, M. D., Professor of the Principles and Practice of Medicine ; W. A. Hammond, M. D., 
Professor of Diseases of the Mind and Nervous System — all of the Bellevue Hospital Medical 
College. 

" This work will be found interesting to every physician. A number of important results 
were obtained valuable to the physiologist." — Cincinnati Medical Repertory. 

HAMILTON 

Clinical Electro-Therapeutics. {Medical 

and Surgical.) A Manual fm' Physicians for the 
Treatment more especially of Nervous Diseases, 
Bj ALLAN McLANE HAMILTON", M. D., 

Physician in charge of the New York State Hospital for Diseases of the Nervous System ; 
Member of the New York Neurological and County Medical Societies, etc., etc. 

With Numerous Illustrations. 1 vol., 8vo, Cloth. Price, $2.00. 

This work is the compilation of well-tried measures and reported cases, and is intended as 
a simple guide for the general practitioner. It is as free from confusing theories, technical 
terms, and unproved statements, as possible. Electricity is indorsed as a very valuable remedy 
in certain diseases, and as an invaluable therapeutical means in nearly all forms of NEEvoira 
Disease ; but not as a specific for every himian ilL mental and physical. 

HAMMOND. 

Insanity in its Relations to Crime. 

A Text and a Commentary. 

By WILLIAM A. HAMMOND, M. D. 
1 vol. 8vo. 77 pp. Cloth, $1.00. 

" A part of this essay, tmder the title ' Society 'oerstis Insanity,' was contributed to Put' 
nam's Magazine^ for September, 1870. The greater portion is now first pubhshcd. The im- 
portance of the subject considered can scarcely be over-estimated, whether we regard it from 
the stand-point of science or social economy ; and, if I have aided in its elucidation, my object 
will have been attained."— #roOT Author'' s Preface,, 



12 2). Appleton <& Co.^s Medical PuhUcations. 

HAMMOND. 
A Treatise on Diseases of the Nervous 

System, 

By WILLIAM A. HAMMOND, M. D., 

Professor of Diseases of the Mind and Neirons System, and of Clinical Medicine, in the Belleme 
Hospital Medical College ; Physician-io-Chief to the New York State Hospital for Diseasee 
of the Nervous System, etc., etc. 

FOXJUTH EDITION, REVISED AND COERECTED. 

With Forty-five Ulnstrations. 1 vol., 8vo. 760 pp. Clotli, $5.00. 

The treatise embraces an introductory chapter, which relates to the 
instruments and apparatus employed in the diagnosis and treatment of 
diseases of the nervous system, and five sections. Of these, the first 
treats of diseases of the brain ; the second, diseases of the spinal cord ; 
the third, cerebro-spinal diseases ; the fourth, diseases of nerve-cells ; 
and the fifth, diseases of the peripheral nerves. One feature which may 
be claimed for the work is, that it rests, to a great extent, upon the per- 
sonal observaMon and experience of the author, and is therefore no mere 
compilation. 

This work is already universally popular with the profession ; their 

appreciation of it may be evidenced by the fact that within two yeaiB 

it has reached the fourth edition. 



" That a treatise by Prof. Hammond -would be one of a high order was what we anticipated, 
and it affords us pleasure to state that our anticipations have been reaUzed." — Cincinnati 
Medical Repertory. 

" This is unquestionably the most complete treatise on the diseases to which it is devoted 
that has yet appeared in the English language ; and its value is much increased by the fact that 
Dr. Hammond has mainly based it on his own experience and practice, which, we need hardly 
remind our readers, have been very extensive." — London Medical Times and Gazette. 

" Free from useless verbiage and obscurity, it is evidently the work of a man who knows 
what he is writing about, and knows how to write about it." — Chicago Medical Journal. 

"■ This is a valuable and comprehensive book ; it embraces many topics, and extends over a 
wide sphere. One of the most valuable parts of it relates to the Diseases of the Brain ; while 
the remaining portion of the volume treats of the Diseases of the Spinal Cord, the Cerebro- 
spinal System, the Nerve-Cells, and the Peripheral 'iS&cYe&"— British Medical Journal. 

" The work before us is unquestionably the most exhaustive treatise, on the diseases to 
which it is devoted, that has yet appeared in EngUsh. And its distinctive value arises from 
the fact that the work is no mere rafficiamento of old observations, but rests on his own ex- 
perience and practice, which, as we have before observed, have been very extensive."— J.wier*- 
can Journal of Syphilography. 

" The author of this work has attained a high rank among our brethren across the Atlantic 
from previous labors in connection with the disorders of the nervous system, as well as from 
various other contributions to medical literature, and he now holds the official appointments of 
Physician to the New York State Hospital for Diseases of the Nervous System, and Professor 
of the same department in the Bellevue Hospital Medical College. The present treatise is the 
fruit of the experience thus acquired, and we have no hesitation in pronouncing it a most valu- 
able addition to our systematic Uterature." — Glasgow Medical Journal. 



D, Appleton db Co.^s Medical Publications. 



13 



HOFFMANlSr. 
Manual of Chemical Analysis, as appued 

to the Examination of Medicinal Chemicals and their 
Preparations, A Guide for the Determination of their 
Identity and Quality^ and for the Detection of Impuri- 
ties and Adulterations, For the use of Pharmaceutists^ 
Physicians, Druggists, and Manufacturing Chemists, and 
Pharmaceutical and Medical Students. 

By FRED. HOFFMANN, Phil. D. 

Oue vol., 8vo. KicWy Illustrated. Cloth. Price, $3. 

SPECIMEN OF ILLirSTEATIONS. 




This volume is a carefully -prepared work, and well up to the existing state of both the science 
and art of modern pharmacy. It is a book which will 'find its place in every medical and phar- 
maceutical laboratory and 'library, and is a safe and instructive guide to medical students and 
practitioners of medicine." — American Journal of Science and Arts. 

In America this work has already met with general and unqualified approval ; and in Europe 
is now being welcomed as one of the best and most important additions to modern pharmaceu- 
tical literature. 

Send for descriptive circular. Address 

D. APPLETON & CO., 549 & 551 Broadway, N. Y. City. 



14 I>. Appleton db Co.'^s Medical Publications, 

HOLLAND. 

Recollections of Past Life, 

By SIR HENRY HOLLAND, Bart., M. D., F. R. S., K C. B., etc., 
President of the Royal Institution of Great Britain, Physician-tn-Ordinary to tlie Queen, 

etc., etc. 

1 vol., 12mo, 351 pp. Price, Cloth, $2.00. 

A very entertaining and instructive narrative, partaking somewhat of the nature of 
autobiography and yet distinct from it, in this, that its chief object, as alleged by the 
writer, is not so much to recount the events of his own life, as to perform the office of 
chronicler for others with whom he came in contact and was long associated. 

The " Life of Sir Henry Holland " is one to be recollected, and he has not erred in giv- 
ing an outline ot it to the public." — The Lancet. 

" His memory was— is, we may say, for he is still alive and in possession of all his 
faculties— stored with recollections of the most eminent men and women of this cen- 
tury. ... A life extending over a period of eighty-four years, and passed in the most 
active manner, in the midst of the best society, which the world has to offer, must neces- 
sarily be full of singular interest ; and Sir Henry Holland has fortunately not waited until 
his memory lost its freshness before recalling some of the incidents in it."— TAe New 
York Times. 

HOWE. 
Emergencies, and How to Treat Them. 

The JEtiology, Pathology, and Treatment of Accidents, 
Diseases, and Gases of Poisoning, which demand 
Prompt Attention. Designed for Students and Prac- 
titioners of Medicine, 

By JOSEPH W. HOWE, M.D., 

Clinical Professor of Surgery in the Medical Department of the University of New York ; 

Visiting Surgeon to Charity Hospital; Fellow of the New York Academy 

of Medicine, etc., etc. 

1 vol., 8vo. Clotli, $3.00. 

"This work has a taking title, and was written by a gentlemen of acknowledged ability, to 
fill a void in the profession. ... To the general practitioner in towns, villages, and in the 
country, where the aid and moral support of a consultation cannot be availed of, this volume 
will be recognized as a valuable help, "We commend it to the profession. — Cincinnati Lancet 
and Observer. , , l-,.^ t. ^ 

" This work is certainly novel in character, and its usefulness and acceptability are as marked 
as its novelty. . . . The book is confidently recommended." — Bichmond and Louisville Med- 
ical Jaurnal. ^ ^ ,..,,.« x x 

" This volume is a practical illustration of the positive side of the physician's life, a constant 
reminder of what he is to do in the sudden emergencies which frequently occur in practice. 
. . . The author wastes no words, but devotes himself to the description of each disease as if 
the patient were under his hands. Because it is a good book we recommend it most heartily to 
the profession.'"— 5os^o« Medical and Surgical Journal. 

" This work bears evidence of a thorough practical acquaintance with the different branches 
of the profession. The author seems to possess a peculiar aptitude for imparting instruction 
as weir as for simplifying tedious details. ... A careful perusal will amply repay the student 
and practitioner.' —iV&20 York Medical Jov/rnaV 



D. Appleton S Co.^s Medical Puhlications, 15 

HUXLEY AND YOUMANS. 
The Elements of Physiology and 

Hygiene. With Numerous Illustrations. 

By THOMAS H. HUXLEY, LL. D., F. E. S., and 
Wn^LIAM JAY YOUMANS, M. D. 

New and Bevised Edition. 1 vol., 12nio. 420 pp. $1.75. 

A text-book for edncational institutions, and a valuable elementary- 
work for students of medicine. The greater portion is from the pen of 
Professor Huxley, adapted by Dr. Youmans to the circumstances and 
requirements of American education. The eminent claim of Professor 
Huxley's " Elementary Physiology " is, that, while up to the times, it 
is trustworthy in its presentation of the subject; while rejecting dis- 
credited doctrines and doubtful speculations, it embodies the latest 
results that are established, and represents the present actual state of 
physiological knowledge. 

" A valuable contribution to anatomical and physiological science." — Religious Telescope. 

"A clear and -weU-arranged work, embracing the latest discoveries and accepted theories." 
—Buffalo Commercial. 

" Teeming with information concerning the human physical enconomy." — Evening Jour- 
nal. 

HUXLEY. 

The Anatomy of Vertebrated Animals. 

By THOMAS HENRY HUXLEY, LL. D., F. R. S., 

Author of "Man's Place in Nature," "On the Origin of Species," "Lay Sermons and 

Addresses," etc. 

1 vol., 12nio. Cloth, $2.50. 

The former works of Prof. Huxley leave no room for doubt as to the impor- 
tance and value of his new volume. It is one which will be very acceptable to 
all who are interested in the subject of which it treats. 

" This long-expected work will be cordially welcomed by aU students and teachers of Com- 
parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most 
comprehensive guide on the subject of which it treats. To praise or to criticise the work of so 
accomplished a master of his favorite science would be equally out of place. It is enough to 
say that it realizes. In a remarkable degree, the anticipations which have been formed of It ; 
and that it presents an extraordinary combination of wide, general views, with the clear, accu- 
rate, and succinct statement of a prodigious number of individual facts."— JVa^?i/"6. 



16 -Z>. Appleton <& Co.''s Medical Publications, 

JOHNSON. 

The Chemistry of Common Life. 

Illustrated with numerous Wood Engravings. 
By JA^JIES r. JOHNSON, M. A., F. E. S., F. G. S., etc., etc., 

A-uthor of "Lectures on Agricultural Chemistry and Geology," "A Catechism of Agricultural 

Chemistry and Geology," etc 

2 vols., 12nio. Clotli, $3.00. 
It has been the object of the author in this work to exhibit the 
present condition of chemical knowledge, and of matured scientific 
opinion, upon the subjects to which it is devoted. The reader will not 
be surprised, therefore, should he find in it some things which differ 
from what is to be found in other popular works already in his hands or 
on the shelves of his library. 

LETTERMAN. 
Medical Recollections of the Army of 

the Potomac, 

By JONATHAN LETTERMAN, M. D., 

Late Surgeon U. 8. A., and Medical Director of the Army of the Potomac, 
1 vol., 8vo. 194 pp. Clotli, $1.00. 
" This account of the medical department of the Army of the Poto- 
mac has been prepared, amid pressing engagements, in the hope that 
the labors of the medical officers of that army may be known to an in- 
teUigent people, with whom to know is to appreciate ; and as an affec 
tionate tribute to many, long my zealous and efficient colleagues, who, 
in days of trial and danger, which have passed, let us hope never to re- 
turn, evinced their devotion to their country and to the cause of hu- 
manity, without hope of promotion or expectation of reward." — Preface. 

" We venture to assert that but few who open this volume of medical annals, 
pregnant as they are with instruction, will care to do otherwise than finish them 
at a sitting." — Medical Record. 

" A graceful and affectionate tribute." — N. Y. Medical Journal. 

LEWES. 
The Physiology of Common Life. 

By GEORGE HENRY LEWES, 

Author of "Seaside Studies," "Life of Goethe," etc. 

2 vols., 12mo. Cloth, $3.00. 

The object of this work differs from that of all others on popular 

science in its attempt to meet the wants of the student, while meeting 

those of the general reader, who is supposed to be wholly unacquainted 

with anatomy and physiology. 



D, Appleton <& Co.^s Medical Publicatioitn. 17 

MAiroSLEY. 
The Physiology and Pathology of the 

Mind, 

By HENRY MAUDSLEY, M. D., London, 

physician to the "West London Hospital; Honorary Member of the Medico-Psychological Society 
of Paris ; formerly Resident Physician of the Manchester Koyal Lunatic Hospital, etc 

1 vol., 8vo. 442 pp. Cloth, $3.00. 

This work aims, in the first place, to treat of mental phenomena from 
a physiological rather than from a metaphysical point of view ; and, 
Becondly, to bring the manifold instructive instances presented by the 
unsound mind to bear upon the interpretation of the obscure problems 
of mental science. 

** Dr. Maudsley has had the courage to undertake, and the skill to execute, 
what is, at least in English, an original enterprise." — London Saturday Review. 

*' It is so full of sensible reflections and sound truths that their wide dissemi- 
nation could not but be of benefit to all thinking persons." — PsychologicalJoiornal. 

" Unquestionably one of the ablest and most important works on the subject 
of which it treats that has ever appeared, and does credit to his philosophical 
acumen and accurate observation." — Medical Record. 

*' "We lay down the book with admiration, and we commend it most earnestly 
to our readers as a work of extraordinary merit and originality — one of those 
productions that are evolved only occasionally in the lapse of years, and that 
serve to mark actual and very decided advances in knowledge and science." — 
N. Y. Medical Journal. 

Body and Mmd : A^i inquiry into their Con- 
nection and Mutual Influence, especially in reference 
to Mental Disorders ; an enlarged a7id revised edition 
to which are added Psychological Ussays, 

By HEN-RY MAUDSLEY, M. D., London, 

FeUow of the Eoyal College of Physicians; Professor of MedicalJurisprudence in Universitv Col- 
ltF®\^^i'-'^^°Ti P^iesident-elect of the Medico-Psychol«gical Association ; Honorary Member of 
the Medico-Psychological Society of Paris, of the Imperial Society of Physicians of Vienna, 
and of the Society for the Promotion of Psychiatry and Forensic Psychology of Vienna • 
formerly Eesident Physician of the Manchester Eoyal Lunatic Asylum, etc., etc. ' 

1 vol., 12mo. 155 pp. Cloth, $1.00. 

The general plan of this work may be described as being to bring 
man, both in his physical and mental relations, as much as possible with- 
in the scope of scientific inquiry. 

"A representative work, which every one must study who desires to know 
what IS domg m the way of real progress, and not mere chatter, about mental 
physiology and pathology."— T'Ae Lancet. 

" It distinctly marks a step in the progress of scientific psychology."— 77i* 
Practitioner. f j cj 



18 I). App'Aton d' Co.'s Jftdccal Publications. 

MAUDSLEY. 
Responsibility in [Mental Diseases. 

Bt HES'RT ilAlDSLET. Y. p.. 
Fellow (^ the Eoyal CkiBege of FnvsclaTis. Prr-fesscr of Mfi : :ir:;;niT-:^e i:: r:-iver?ny 
Cfdiege, LandcHL, ^e^ etc Ai:!;- ::" 2: :^1 22^ii ri-- :;. :^'7 :^i P:.-Ji;.:r7 o: tie 
I7<aTaiis System." 

1 vol,, 12mo. 313 pp. Clotiu $1.50. 

"This book is a compact presentatioii of those facts and principles which re- 
T-re to be taken into account in estimating human responsibility — not l^al 
: r ;:ir.bilitv merely^ but responsibility for conduct in the family, the school, and 
all phases of social relation in which obligation enters as an element. The work 
IS new in plan, anl was written to supply a widely-felt want which has not 
hi^erto been m^" — The Popular SdeBce Monthly. 



MARKOE. 

A Treatise on Diseases of the Bones. 

By TH':>yj.S M. ^lAEKOE. M. D.. 
Pr::.~s;: :: ^irrrr- - :ir C^lrrf li p--?:::-^ :r: =-^r:z?, Xew York., etc 

WITH NTMEEOrS ILLU S T E A T 10 X S . 

1 vol.. 8vo. Cloth. 84. 5-0. 

This valuable work is a treatise on Diseases of the Bones, embracing their 
structural changes as affected by disease, their clinical history and treatment, in- 
cluding also an account of the various tumors which grow in or upon them. Xone 
of the injuries of bone are included in its scope, and no joint diseases, excepting 
where the condition of the bone is a prime factor in the problem of disease. As 
the work of an eminent surgeon of large and varied experience, it may be regarded 
as the best on the subject, and a valuable contribution to medical hterature. 

"llie book wiiidL I now oiRET to my professMmal Ire^Oam. eontams the sabetancc :: .1? 
ketmes whidi I have d^vered dmiiig the past twrfve years at the eoll^e. ... I have : : !! — t i 
ijie leadiiigs of mv own studies and ohea-va&ais, dwdfinsr more on those branches whf r I ^ i 
seen and studied most and peih^s too mudi i^gleeting' othos where mr own experlTi t - :~ 
mwe barren, and thCTefore to me less interestii^. I have endesTored, however, to mss: t i : : :i t 
defidaieies of my own isiowledge by titie free use of ihe matesdals scattered so nstl- :1: : ~ r J: 
OUT paiodieal fitexature, wiiidi scattered leaves it istiie right and the doty of tiie rrrr^ir.: 
writer to eoDeet and to embody in any aeeoont he may ofiEer d the state of a sdenee at 2:17 z--z 
^eno<L"—Brtraetfrom, AuSkor'a Pr^aee. 



2>. Appleton S Co.^s Medical Fuhlications. 19 

MEYER 
Electricity in its Relations to Practical 

Medicine, 

By De. MOEITZ MEYER, 

Eoyal Counsellor of Health, etc. 

Translated txom. the TMrd German Edition, with Notes and Additions, 
A New and Revised Edition, 

By WILLIAM A. HAMMOND, M. D., 

Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Bellevua 
Hospital Medical College ; Vice-President of the Academy of Mental Sciencefs National 
Institute of Letters, Arts, and Sciences ; late Surgeon-Genera* U. S. A., etc. 

1 vol., 8vo. 497 pp. Cloth, $4.50. 

" It is the duty of every physician to study the action of electricity, 
to become acquainted with its value in therapeutics, and to follow the 
improvements that are being made in the apparatus for its application in 
medicine, that he may be able to choose the one best adapted to the 
treatment of individual cases, and to test a remedy fairly and without 
prejudice, which already, especially in nervous diseases, has been used 
with the best results, and which promises to yield an abundant harvest 
in a still broader domain." — From Author''s Preface. 

8PB0IMEN OF ILLU8TEATION8. 




Sajcton-Ettlnghansen Apparatus. 

" Those who do not read German are under great obligations to William A. 
Hammond, who has given them not only an excellent translation of a most ex- 
cellent work, but has given us much valuable information and many suggestions 
from his own personal experience." — Medical Record. 

" Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious 
and conscientious student of the application of electricity to practical medicine, 
and the results of his labors are given in this volume. Dr. Hammond, in making 
a translation of the third German edition, has done a real service to the profession 
of this country and of Great Britain. Plainly and concisely written, and simply 
and clearly arranged, it contains just what the physician wants to know on the 
subject." — N. T. Medical Journal. 

" It is destined to fill a want long felt by physicians in this country." — Journai 
of Obstetrics. 



20 -Z>. AppUton S Go.^s Medical Fublications. 

NIEMEYER 
A Text-Book of Practical Medicine. 

With Particular Reference to Physiology and Patho- 
logical Anatomy. 

By the late Dr. FELIX YON NIEMEYER, 

Professor of Pathology and Tlierapeutics ; Director of the Medical Clinic of the University of 

Tubingen. 

Translated from the Eigrhth German Edition, by special permission of 

tlie Author, 

By GEORGE H. HUMPHREYS, M. D., 

Late >ne of the Physicians to the Bureau of Medical and Surgical Eelief at Bellevue Hospital for 
the Out-door Poor ; Fellow of the New York Academy of Medicine, etc., 

and 

CHARLES E. HAOKLEY, M. D., 

One of the Physicians to the New York Hospital; one of the Surgeons to the New York Eye 
and Ear Infirmary ; Fellow of the New York Academy of Medicine, etc. 

Eevised Edition. 2 vols., 8vo. 1,528 pp. Cloth, $9.00 ; Sheep, 811.00. 

The author undertakes, first, to give a picture of disease which shall 
be as lifelike and faitliful to nature as possible, instead of being a mere 
theoretical scheme ; secondly, so to utilize the more recent advances 
of pathological anatomy, physiology, and physiological chemistry, as to 
furnish a clearer insight into the various processes of disease. 

The work has met with the most flattering reception and deserved 
success ; has been adopted as a text-book in many of the medical colleges 
both in this country and in Europe; and has received the very highest 
encomiums from the medical and secular press. 

"It is comprehensive and concise, and is characterized by clearness and 
originality." — Dublin Quarterly Journal of Medicine. 

" Its author is learned in medical literature ; he has arranged his materials 
with care and judgment, and has thought over them." — TJie Lancet. 

"As a full, systematic, and thoroughly practical guide for the student and 
physician, it is not excelled by any similar treatise in any language." — Appletons* 
Journal. 

" The author is an accomplished pathologist and practical physician ; he is not 
only capable of appreciating the new discoveries, which during the last ten years 
have been unusually numerous and important in scientific and practical medicine, 
but, by his clinical experience, he can put these new views to a practical test, and 
give judgment regarding them." — Edinburgh Medical Journal. 

" From its general excellence, we are disposed to think that it will soon take 
its place among the recognized text-books." — American Quarterly Journal of 
Medical Sciences. 

" The first inquiry in this country regarding a German book generally is, ' Is 
it a work of practical value ? " Without stopping to consider the justness of the 
American idea of the ' practical,' we can unhesitatingly answer, ' It is ! ' " — New 
York Medical Journal. 

" The author has the power of sifting the tares from the wheat — a matter of 
the greatest importance in a text-book for students." — British Medical Journal. 

" Whatever exalted opinion our countrymen may have of the author's talents 
of observation and his practical good sense, his text-book will not disappoint 
them, while those who are so unfortunate as to know him only by name, have in 
store a rich treat." — New York Medical Record. 



i>. Appleton S Co.'^s Medical Publications, 



21 



NEUMANN. 
Hand-Book of Skin Diseases. 

By Dr. ISIDOR NEUMANN, 
Lecturer on Skin Diseases in the Royal University of Vienna. 

Translated from advanced sheets of the second edition, furnished by the 
Author ; with Notes, 

By LUCIUS D. BULKLEY, A. M., M. D., 

Surgeon to the New York Dispensary, Department of Venereal and Skin Diseases ; Assist- 
ant to the Skin Clinic of the College of Physicians and Surgeons, New York; Mem- 
ber of the New York Dermatological Society, etc., etc. 

1 vol., 8vo. About 450 pages and 66 Woodcuts. Cloth, $4.00. 

8PE0I2IBN OF ILLUSTRATIONS. 




Section of skin from a bald head. 

Prof. Neumann ranks second only to Hebra, who^e assistant he was for many years 
and his work may be considered as a fair exponent of the German practice of Dermatolo- 
gy. The book is abundantly illustrated with plates of the histology and pathology of the 
skin. The translator has endeavored, by means of notes from French, English, and Ameri- 
can sources, to make the work valuable to the student as well as to the practitioner. 



"It is a work which I shaU heartily recommend to my class of students at the Univer- 
sity of Pennsylvania, and one which I feel sure will do much toward enlightening the pro- 
fession on this subject.'" — Louis A. Duhring. 

" I know it to be a good book, and I am sure that it is well translated; and it is inter- 
esting to find it illustrated by references to the views of co-laborers in the same field.''— 
Erasmus Wilson. 

" So complete as to render it a most useful book of reference." — T. McCaM Anderson. 

" There certainly is no work extant which deals so thoroughly with the Pathological 
Anatomy of the Skin as does this hand-book."—^. Y. Medical Record. 

" The original notes by Dr. Bulkley are very practical, and are an important adjunct to 
the text. . . . I anticipate for it a wide circulation."— (Sztos Z'Mr^ef. ^04'ton. 

" I have already twice expressed my favorable opinion of the book in print, and am 
glad that it is given to the public at last."— Jame^ C. White, Boston. 

"More than two years ago we noticed Dr. Neumann's admirable work in its original 
shape ; and we are therefore absolved from the necessity of saying more than to repeat 
our strong recommendation of it to Enghsh readers."— PmcieYiOner. 



22 D. Appleton <& Co.'^s Medical IhiUications. 

NEFTEL. 

GalvanO-TherapeutlCS. The Physwloglcal and 
Therajyeiitical Action of the Galvanic Current upcni 
the Acoustic, Oj)tic, Symjpathetie, and Pneumogastric 

Nerves. 

Bv TTILLIAil B. ISTEFTEL. 
1 vol., 12mo. 161 pp. Cloth, $1.50. 

This book has been publisTied at the reqnest of several anral sur- 
geons and other professional gentlemen, and is a valnable treatise on 
the subjects of which it treats. Its author, formerly visiting physician 
to the largest hospital of St. Petersburg, has had the very best facili- 
ties for investigation. 

" This little -work shows, as far as it goes, fuU kno-wledge of what has been 
done on the subjects treated of, and the author's practical acquaintance with 
them." — New York Medical Journal. 

" Those who use electricity should get this work, and those who do not 
should peruse it to learn that there is one more therapeutical agent that they 
could and should possess." — Th£ Medical Investigator. 

NIGHTINGALE. 

Notes on Nursing: what it is, and what it is not. 

By FLOEEXCE XIGHTINGALE. 
1 voL, 12mo. 140 pp. Cloth, 75 cents. 
Every-day sanitary knowledge, or the knowledge of nursing, or, in 
other words, of how to put the constitution in such a state as that it will 
have no disease or that it can recover from disease, takes a higher place. 
It is recognized as the knowledge which every one ought to have — dis- 
tinct from medical knowledge, which only a profession can have. 

PEKEIRA. 

Dr. Pereira's Elements of Materia 

Mediea OMd Tkerajpeutics. Alridged and adapted 
for the Use of Medical and Pharmaceutical Practi- 
tioners cmd Students, o/nd comprising all the Medi- 
ernes of the British Pharmacopxda, with such others 
as are frequently ordered in PresG'rip>tions, or re- 
quired 'by the Physician. 

Edited by EGBERT BEXTLEY and THEOPHILUS EEDWOOD. 

New Edition. Brought down to 1872. 1 vol., Eoyal 8vo. Cloth, S7.00; 
Sheep, $8.00. 



D. Appleton <& Co,^s Medical Publications. 23 

PEASLEE. 

Ovarian Tumors ; Tlieir Pathology, Diagnosis, 
and Treatment, with reference esjpecially to Ovariotomy, 
Bj E. E. PEASLEE, M. D., 

Professor of Diseases ofWomen in Dartmouth Collef^e; one of the Consulting' Physicians to 
the JSTew York State "Woman's Hospital ; formerly Professor of Obstetrics and Diseases of 
Women in the New York Medical College; Corresponding Member of the Obstetrical 
Society of Berlin, etc. 

1 vol., 8vo. Illustrated with many "Woodcuts, and a Steel Engraving of Dr. 
E. McDowell, the " Father of Ovariotomy." Price, Cloth, $5.00. 

This valuable work, embracing the results of many years of successful experience in the 
department of which it treats, will prove most acceptable to the entire profession ; while the 
high standing of the author and his knowledge of the subject combine to make the book the 
best in the language. It is divided into two parts : the first treating of Ovarian Tumors, their 
anatomy, pathology, diagnosis, and treatment, except by extirpation ; the second of Ovariot- 
omy, its history and statistics, and of the operation. Fully illustrated, and abounding with 
Ie formation the result of a prolonged study of the subject, the work should be in the hands of 
every physician in the country. 

The following are some of the opinions of the press, at home and abroad, of this great 
work, which has been justly styled, by an eminent critic, " the most complete medical m/)no- 
graph on a practical subject ever produced in this country.'''' 

" His opinions upon what others have advised are clearly set forth, and are as interesting 
and important as are the propositions he has himself to advance ; while there are a freshness, 
a vigor, an authority about his writing, which great practical knowledge alone can confer." — 
The Lancet. 

" Both Wells's and Peaslee's works will be received veith the respect due to the great repu- 
tation and skill of their authors. Both exist not only as masters of their art, but as clear and 
graceful writers. In either work the student and practitioner vdll find the fruits of rich expe- 
rience, of earnest thought, and of steady, well-balanced judgment. As England is proud of 
WeUs, so may America well be proud of Peaslee, and the great world of science may be proud 
of both." — British Medical Jowrnal. 

" This is an excellent work, and does great credit to the industry, ability, science, and 
learning of Dr. Peaslee. Few works issue from the medical press so complete, so exhaustive- 
ly learned, so imbued with a practical tone, without losing other substantial good quahties." 
— Edinburgh Medical Journal. 

" In closing our review of this work, we cannot avoid again expressing our appreciation of 
the thorough study, the careful and honest statements, and candid spirit, which characterize it. 
For the v.se of the student we should give the preference to Dr. Peaslee''8 work^ not only 
from its completeness, hut from its vnore methodical arrangem.ent.^'' — American Journal 
of Medical Sciences. 

" Dr. Peaslee brings to the work a thoroughness of study, a famiharity with the whole 
field of histology, physiology, pathology, and practical gynascology, not excelled, perhaps, by 
those of any man who ever performs the operation." — Medical Record. 

" If we were to select a single word to express what we regard as the highest excellence of 
this book, it would be its thoroughness.'''' — New York Medical Journal. 

" We deem its careful perusal indispensable to all who would treat ovarian tumors with a 
good conscience." — American Journal of Obstetrics. 

" It shows prodigal industry, and embodies within its five hundred and odd pages pretty 
much all that seems worth knowng on the subject of ovarian ^isea^e?,.''''— Philadelphia Medi- 
cal Times. 

" Great thoroughness is shown in Dr. Peaslee's treatment -of all the details of this very ad- 
mirable vfovk..''^— Boston MeMcal and Swrgical Journal. 

"It is a necessity to every surgeon who expects to treat this disease." — Lea/vewworth 
Medical Herald. 

" Indispensable to the American student of gynaecology."— Pac»;Zc Medical and JSurgical 
Journal. 

" There is not a doubtful point that could occur to any one that is not explained and an- 
swered in the rnost satisfactory manner."— Virginia Clinical Record. 

" The work is one the profession should prize ; one that every earnest practitioner should 

i&QSS,.''''— Georgia Medical Companion. 

" Dr. Peaslee has achieved a success, and the work is one which no practical surgeon can 
afibrd to be without."— J/ed*caZ Investigator. 



24 D. Applet o/i c& Co.h Medical Publications, 

SAYKS. 
A Practical Manual on the Treatment 

of Cluh-Foot, 

Bv LEWIS A. SATRE, M. D., 

Professor of Orthopedic Surgery in BeUe-rae Hospital Medical College ; Surgeon to BeHevue 
and Charity Hospitals, etc 

1 vol., 12mo. New and Enlarged Edition. Qoth. $1.00. 

" The object of this work is to convey, in as concise a manner as possible, 

all the practical information and instruction necessary to enable the general 

practitioner to apply that plan of treatment which has been s9 successful in my 

own hands." — Preface. 

" The book will rerr well satisfy the wants of the majority of general practitioners, for 
whose use, as stated, it is intended."— J^'ew; York Medical Journal. 

SMITH. 
On Foods. 

By EDWARD SMTH, M. D., LL. B., F. B. S., 

Fellow of the Eoyal College of Physicians of London, etc^ etc. 

1 vol., 12mo. Cloth. Price, $1.75. 

Since the issue of the author's work on " Practical Dietary," he has 
felt the want of another, which would embrace all the generally-known 
and less-known foods, and contain the latest scientific knowledge re- 
specting them. The present volume is intended to meet this want, and 
will be found useful for reference, to both scientific and general read- 
ers. The author extends the ordinary view of foods, and includes 
water and air, since they are important both in their food and sanitary 
aspects. 

■STROUD. 
The Physical Cause of the Death of 

Christy and its Relations to the Princi;ples and Prac- 
tice of Cliristianity. 

By WILLIAM STROUD, M. D. 

"With a Letter on the Suhject, 

By Sir JAMES T. SIMPSON, Baet.,M.D. 

1 vol., 12mo. 422 pp. Cloth, $2.00. 

This important and remarkable book is, in its own place, a masterpiece, and 
will be considered as a standard work for many years to come. 

The principal point insisted upon is. that the death of Christ was caused by rupture or lacer- 
ation of the heart. Sir James T. Simpson, who had read the author's treatise and various com- 
ments on it expressed himself very positively in favor of the views maintained by Dr. Stroud. 
—Psychological Journal. 



D. Appleton & Co!'s Medical Publications. 25 

SIMPSOK. 
The Posthumous Works of Sir James 

Young Simpson, Bart, M. D. In Three Volumes. 

Volume I. — Selected Obstetrical and Gynaecological Works of 
Sir James Y. Simpson, Bart., M. D., D. C. L., late Professor of Midwifery 
in the University of Edinburgh. Containing the substance of his Lect- 
ures on Midwifery. Edited by J. Watt Black, A, M., M. D., Member of 
the Royal College of Physicians, London ; Physician- Accoucheur to Char- 
ing Cross Hospital, Loudon ; and Lecturer on Midwifery and Diseases of 
Women and Children in the Hospital School of Medicine. 

1vol., 8vo. 852 pp. Cloth, $3.00. 

This voiume contains all the more important of the contributions of 
Sir James Y. Simpson to the study of obstetrics and diseases of women, 
with the exception of his clinical lectures on the latter subject, which 
will shortly appear in a separate volume. This first volume contains 
many of the papers reprinted from his Obstetric Memoirs and Contri- 
butions, and also his Lecture JTotes, now published for the first time, 
containing the substance of the practical part of his course of mid- 
wifery. It is a volume of great interest to the profession, and a fitting 
memorial of its renowned and talented author. 

" To many of our readers, doubtless, the chief of the papers it contains are familiar. To 
others, although probably they may be aware that Sir James Simpson has written on the sub- 
jects, the papers themselves wiU be new and fresh. To the first class we would recommend 
this edition of Sir James Simpson's works, as a valuable volume of reference; to the latter, as 
a collection of the works of a great master and improver of his art, the study of which cannot 
fail to make them better prepared to meet and overcome its difficulties." — Medical Times and 
Gazette. 

Volume II. — Anaesthesia^ Hospitalism^ etc. Edited by Sir 

Walter Simpson, Bart. 

1 vol., 8vo. 660 pp. Cloth, S3.00. 

" "We say of this, as of the first volume, that it should find a place on the table of every 
practitioner ; for, though it is patchwork, each piece may be picked out and studied with pleas- 
ure and profit."— TAe Lancet {^London). 

Volume III. — The Diseases of Women. Edited by Alex. Simp- 
son, M. D., Professor of Midwifery in the University of Edinburgh. 
1 vol., 8vo. Cloth, $3.00. 

One of the best works on the subject extant. Of inestimable value to every physician. 

SWETT. 
A Treatise on the Diseases of the Chest. 

Being a Course of Lectures delivered at the New 
York Hospital. 

By JOHN A. SWETT, M. D., 

Professor of the Institutes and Practice of Medicine in the l!few York University ; Physiciaa 
to the New York Hospital ; Member of the New York Pathological Society, 

Ivol., 8vo. 587 pp. $3.50. 

Embodied in this volume of lectures is the experience of ten years in hospital and private 
practice. 



26 D' Appleton & Co.''s Medical Publications, 

SCHBOEDER 
A Manual of Midwifery, including the 

Pathology of Pregnancy amd the Puerjyeral State, 
By Dr. KARL SOHROEDER. 

Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen. 

Translated from the TMrd German Edition, 

By OHAS. H. CARTER, B. A., M. D., B. S. Lond., 

Member of the Koyal College of Physicians, London, and Physician Accoucheur to St G-eorge's, 
Hanover Square, Dispensary. 

"With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth. 

" The translator feels that no apoloCT' is needed in oflfering to the profession a translation 
of Schroeder's Manual of Midvsrifery. The work is well known in Germany and extensively 
used as a text-book ; it has aheady reached a third edition within the short space -^f two years, 
and it is hoped that the present translation will meet the want, long felt in this country, of a 
manual of midwifery embracing the latest scientific researches on the subject. 

TILT. 

A Hand-Book of Uterine Therapeu- 

tics and of Diseases of Women, 

By EDWARD JOHN TILT, M. D., 

Member of the Eoyal College of Physicians ; Consulting Physician to the Farringdon General 
Dispensary ; Fellow of the Eoyal Medical and Chirurgical Society, and of several British 
and foreign societies. 

1 vol., 8vo. 345 pp. Clotli, $8.50. 

Second American edition, thorouglily revised and amended. 

" In giving the result of his labors to the profession the author has done a great work. Our 
readers will find its pages very interesting, and, at the end of their task, will feel gratefal to 
the author for many very valuable suggestions as to the treatment of uterine diseases." — The 
Lancet. 

"Dr. Tilt's ' Hand-Book of Uterine Therapeutics' supplies a want which has often been 
felt. ... It may, therefore, be read not only with pleasure and instruction, but wiU also be 
found very useful as a book of reference."— 7%6 Medical Mirror. 

" Second to none on the therapeutics of uterine disease."— «7bzw'7iaZ of Oisietrics. 

VAN BUREN. 

Lectures upon Diseases of the Rectum. 

Delivered at the Bellevue Hospital Medical College. 
Session of 1869-'70. 

By W. H. VAN BUREN, M. D., 

Professor of the Principles of Surgery with Diseases of the Genitp-ITrinary Organs, etc.. In the 
Bellevue Hospital Medical College ; one of the Consulting Surgeons of the New Tork Hos- 
pital, of the BeUevue Hospital ; Member of the New York Academy of Medicine, of the 
Pathological Society of New York, etc., etc. 

1 vol., 12mo. 164 pp. Clotli, $1.50. 

" It seems hardly necessary to more than mention the name of the author of this admirable 
little volume in order to insure the character of his book. No one in this country has enjoyed 
greater advantages, and had a more extensive field of observation in this specialty, than Dr. 
van Buren, and no one has paid the same amount of attention to the subject. . . . Here is the 
experience of years summed up and given tO the professional world in a plain and practical 
manner."' — Psychological Journal. 



D. AppUton db Co.^s Medical JPuhlications. 27 

VAN BUREN AND KEYES. 
A Practical Treatise on the Surgical 

Diseases of the Genito- Urinary Organs^ including Syphi- 
lis. Designed as a Matiual for Students and Practition- 
ers. With Engravings and Gases. 

By W. H. van BUREN, A. M., M. D., 

Professor of Principles of Surgery, vritk Diseases of the Genito-TJrinary System and Clinical 

Surgery, in Bellevue Hospital Medical College ; Consulting Surgeon to the New York 

Hospital, the Charity Hospital, etc. ; and 

E. L. KEYES, A. M., M. D., 

Professor of Dermatology in Bellevue Hospital Medical College ; Surgeon to the Charity Hospi- 
tal, Venereal Division ; Consulting Dermatologist to the Bureau of Out-Door Eehef, 
Bellevue Hospital, etc. 

1 vol., 8vo. Cloth, $5.00; Sheep, $6.00. 

This work is really a compendium of, and a book of reference to, all modern 
works treating in any way of the surgical diseases of the genito-urinary organs. 
At the same time, no other single book contains so large an array of original 
facts concerning the class of diseases with which it deals. These facts are 
largely drawn from the extensive and varied experience of the authors. 

Many important branches of genito-urinary diseases, as the cutaneous mala- 
dies of the penis and scrotum, receive a thorough and exhaustive treatment that 
the professional reader will search for elsewhere in vain. 

Both to the specialist and the general practitioner the work commends itself 
as one of inestimable value. 

The work is a marvel of conciseness, and very rarely is so much condensa- 
tion accomplished without loss of any valuable points of detail. A glance at 
the table of contents will give an idea of the scope of the volume, but only a 
careful perusal of the work will convince the reader that full justice has been 
done to all the various branches of this highly-interesting class of diseases. 

The work is elegantly and profusely illustrated, and enriched by fifty-five 
original cases, setting forth obscure and difficult points in diagnosis and treatment. 

" The first part is devoted to the Surgical Diseases of the Genito-Urinary 
Organs; and part second treats of Chancroid and Syphilis. The authors 'ap- 
pear to have succeeded admirably in giving to the world an exhaustive and 
reliable treatise on this important class of diseases.'" — Northwestern Medical and 
Surgical Journal. 

" It is a most complete digest of what has long been known, and of what has 
been more recently discovered in the field of syphilitic and genito-urinary dis- 
orders. It is perhaps not an exaggeration to say that no single work upon the 
same subject has yet appeared, in this or any foreign language, which is superior 
to it." — Chicago Medical Examiner. 

" The commanding reputation of Dr. Van Buren in this specialty and of the 
great school and hospital from which he has drawn his clinical materials, together 
with the general interest which attaches to the subject-matter itself, will, we 
trust, lead very many of those for whom it is our ofiice to cater, to possess them- 
selves at once of the volume and form their own opinions of its merit." — Atlanta 
Medical and Surgical Journal. 



28 D. Appleton <& Co.^s Medical PuhUcations, 

VOQEL. 
A Practical Treatise on the Diseases 

of Children. Second American from the Fourth 
German Edition, Illusi/rated hy Six Lithographic 
Plates. 

By ALFEED YOGEL, M. D., 

Professor of Qlnical Medicine in the University of Dorpat, Eussia. 
TEAN8LATED AXD EDITED BY 

H. E APHAEL, M. D., 

Late Eoujse Surgeon to Bellerue Hospital ; Physician to the Eastern Dispensary for the DIseaaee 
of Children, etc., etc. 

1 vol., 8vo. 611 pp. Cloth, S4.50. 

The work is "^ell np to the present state of pathological knoTvledge ; 
complete Tvithont unnecessary prolixity; its srmptomatologv accurate, 
evidently the result of carefal observation of a competent and experi- 
enced clinical practitioner. The diagnosis and differential relations of 
diseases to each other are accurately described, and the therapeutics 
judicious and discriminating. All polypharmacy is discarded, and only 
the remedies which appeared useful to the author commended. 

It contains much that must gain for it the merited praise of all im- 
partial judges, and prove it to be an invaluable text-book for the stu- 
dent and practitioner, and a safe and useful guide in the difficult but all- 
important department of Psediatrica. 

"Rapidly passing to a fourth edition in Germany, and translated into three 
other languages, America now has the credit of presenting the first English ver- 
sion of abook which must take a prominent, if not the leading, position among 
works devoted to this class of disease." — N. Y. Medical Journal 

" The profession of this country are under many obligations to Dr. Raphael 
for brino-ing, as he has dona, this truly valuable work to their notice." — Medical 
Record. 

"The translator has been more than ordinarily successful, and his labors 
have resulted in what, in every sense, is a valuable contribution to medicaj 
Bcience." — Psychological Journal. 

" We do not know of a compact text -book on the diseases of children more 
complete, more comprehensive, more replete with practical remarks and scientific 
facts, more in keeping with the development of modem medicine, and more 
worliiv of the attention of the profession, than that which has been the subject 
of our remarks," — Journal of Obstetrics. 



D. Appleton & Co.^s Medical Publications. 29 

WALTON. 

The Mineral Springs of the United 

States and Canada, with Analyses and Notes on the 
Prominent Spas of Europe, and a List of Sea-side 
Resorts, An enlarged and revised edition. 

By GEOEGE E. WALTON", M.D., 

Lecturer on Materia Medica in the Miami Medical College, Cincinnati. 

1 vol., 12mo. 330 pages, with Maps. Price, $2.00. 

The author has given the analyses of all the springs in this country and 
those of the principal European spas, reduced to a uniform standard of 
one wine-pint, so that they may readily he compared. He has arranged 
the springs of America and Europe in seven distinct classes, and de- 
scribed the diseases to which mineral waters are adapted, with refer- 
ences to the class of waters applicable to the treatment, and the pecul- 
iar characteristics of each spring as near as known are given — also, the 
location, mode of access, and post-office address of every spring are men- 
tioned. In addition, he has described the various kinds of baths and 
the appropriate use of them in the treatment of disease. 

EXTRACTS FROM OPINIONS OF THE PRESS. 

"... Precise and comprehensive, presenting not only reliable analyses of 
the waters, but their therapeutic value, so that physicians can hereafter advise 
their use as intelligently and beneficially as they can other valuable alterative 
agents." — Sanitarian. 

"... Will tend to enlighten both the profession and the people on this 
question." — N. Y. Medical Journal. 

"... Contains in brief space a vast amount of important and interesting 
matter, well arranged and well presented. Nearly every physician needs just 
such a volume." — Richmond and Loimville Medical Journal. 

"... Fills this necessity in a scientific and pleasing manner, and can be read 
with advantage by the physician as well as layman," — America'}L Jour, of Obstetrics. 

Unitbesitt of Yieginia, June 9, 1873. 

Gentlemen : I have received by mail a copy of Dr. Walton's work on the 
Mineral Springs of the United States and Canada. Be pleased to accept my 
thanks for a work which I have been eagerly looking for ever since I had the 
pleasure of meeting the author in the summer of IS^l. He satisfied me that 
he was well quahfied to write a reliable work on this subject, and I doubt not 
he has met my expectations. Such a work was greatly needed, and, if offered 
for sale at the principal mineral springs of the country, will, I believe, com- 
mand a ready sale. Yery respectfully yours, 

J. L. Cabell, M. D. 



30 D. Appleton S Go.'^s Medical Publications, 

WELLS. 

Diseases of the Ovaries ; TUir Diagnosis 

and Treatment, 

By T. SPENCER WELLS, 

Fellow and Member of Council of theEoyal College of Surgeons of England; Honorary Fellow 
of the King and Queen's College of Physicians in Ireland; Surgeon in Ordinary to the 
Queen's Household ; Surgeon to the Samaritan Hospital for Women ; Member of the Im- 
perial Society of Surgery of Paris, of the Medical Society of Paris, and of the Medical Soci- 
ety of Sweden ; Honorary Member of the Eoyal Society of Medical and Natural Science 
of Brussels, and of the Medical Societies of Pesth and Helsingfors ; Honorary Fellow of 
the Obstetrical Societies of Berlin and Leipzig. 

1 vol., 8vo. 478 pp. Illustrated. Cloth, Price, $4.50. 

In 1865 the author issued a volume containing reports of one hundred and 
fourteen eases of Ovariotomy, which was little more than a simple record of 
facts. The book was soon out of print, and, though repeatedly asked for a 
new edition, the author was unable to do more than prepare papers for the 
Royal Medical and Chirurgical Society, as series after series of a hundred cases 
accumulated. On the completion of five hundred cases he embodied the resulta 
in the present volume, an entirely new work, for the student and practitioner, 
and trusts it may prove acceptable to them and useful to suffering women. 

" Arrangements have been made for the publication of this volume in Lon- 
don on the day of its publication in New York." French and German transla- 
tions are already in press. 

WAGNER 
A Hand - book of Chemical Tech- 

nology. 

By EUDOLPH WAGNER, Ph. D., 

Professor of Chemical Technology at the University of "Wurtzburg. 

Translated and edited, from the eig-hth. German edition, with extensive 

additions, 

Bj WILLIAM CROOKES, F. R. S. 

With 336 Illustrations. 1 vol., Svo. 761 pages. Cloth, $5.00. 

Under the head of Metallurgic Chemistry, the latest methods of preparing Iron, Cobalt, 
Nickel, Copper, Copper Salts, Lead and Tin, and their Salts, Bismuth, Zinc, Zinc Salts, Cad- 
mium, Antimony, Arsenic, Mercury, Platinum, Silver, Gold, Manganates, Aluminum, and 
Magnesium, are described. The various applications of the Voltaic Current to Electro-Metal- 
lurgy follow under this division. The preparation of Potash and Soda Salts, the manufacture 
of Sulphuric Acid, and the recovery of Sulphur from Soda "Waste, of course occupy prominent 
places in the consideration of chemical manufactures. It is diflficult to over-estimate the mer- 
cantile value of Mond's process, as well as the many new and important applications of Bisul- 
phide of Carbon. The manufacture of Soap will be found to include much detail. The Tech- 
nology of Glass, Stone-ware, Limes, and Mortars, will present much of interest to the Builder 
and Engineer. The Technology of Vegetable Fibres has been considered to include the prep- 
ai-ation of Flax, Hemp, Cotton, as well as Paper-making; while the applications of Vegetable 
Products will be found to include Sugar-boihng, Wine and Beer Brewing, the Distillation of 
Spirits, the Baking of Bread, the Preparation of Vinegar, the Preservation of Wood, etc. 

Dr. Wagner gives much information in reference to the production of Potash from Sugar 
residues. The use of Baryta Salts is also fully described, as well as the preparation of Sugar 
from Beet-roots. Tanning, the Preservation of Meat, Milk, etc., the Preparation of Phospho- 
rus and Animal Charcoal, are considered as belonging to the Technology of Animal Products. 
The Preparation of Materials for Dyeing has necessarily required much space ; while the final 
sections of the book have been devoted to the Technology of Heating and Illumination 



NEW MEDICAL WORKS IN PRESS. 



Hand*>Book of tlie Histolog'y and Histo- 
chemistry of Man. By Dr. Heinrich Frey, of Zurich. Illustrated with 
500 Woodcuts. 

Clinical Lectures on Diseases of tlie 

Nervous System. Delivered at the Bellevue Hospital Medical College, by 
Wm. a. Hammond, M. D. Edited, with Notes, by T. M. B. Cross, M. D. 

AiCne ; its Pathology, Etiology, Prognosis, and Treatment. By L. Duncan 
BcLKLEY, A. M., M. D., New York Hospital. 

A monograph of about seventy pages, illustrated, founded on an analysis of two hundred 
cases of various forms of acne. 

Compendium, of CMldren's Diseases, for 

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Diseases of the Nerves and Spinal Cord. 

By Dr. H. Charlton Bastian. 

D. APPLETON & CO., 

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